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HX641 27338 
RC73 -MBS  1915     Diagnostic  and  thera 



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Diagnostic  and  Therapeutic  Technic 

Octavo  ot  830  pages,  with  860  line- 
drawings.  Cloth,  $5.00  net. 
The  New  {2d)  Edition 

Immediate  Care  of  the  Injured 

i2mo  of  35;  pages,  with  242  illus- 
trations. Cloth,  $2.50  net. 
The  Ne^u  {2d)  Edition 




A    Manual    of  Practical    Procedures 
Employed  in  Diagnosis  and  Treatment 


ALBERT   S.   MORROW.   A.  B.,  M.  D. 






Copyright,  lyit,  by  W.  B.  Saunders  Company.     Reprinted  January, 
1912,   and  January,   1913       Revised,  entirely   reset,  re- 
printed, and  recopyrighted     January,     igi.s 
Reprinted  July,  1915 

Copyri;;ht,  1915,  by  W.  B.  Saunders  Compnny 
Reprinted  November.  IQ15 

CoViNJ       ^ 



W.     B.     SAUNDERS     COMPANY 


To  the  memory  of  my  Father 

Prince  a.  Morrow,  m.  D., 

This  book  is  dedicated 


In  the  short  time  that  has  elapsed  since  the  pubKcation  of  the 
first  edition  of  this  work  many  advances  have  been  made  in  diagnosis 
and  treatment  necessitating  in  the  preparation  of  the  present  edition 
a  very  careful  revision  of  the  old  manuscript  and  the  addition  of 
much  new  material.  Many  new  illustrations  have  been  added  and 
some  of  those  appearing  in  the  previous  edition  have  been  redrawn. 
These  additions  have  resulted  in  a  somewhat  larger  volume,  though 
the  plan  of  the  original  work  has  been  followed  without  change. 
Every  effort  has  been  made  to  bring  the  present  volume  up  to  date 
and  to  maintain  the  thoroughly  practical  character  of  the  original 
work,  and  it  is  earnestly  hoped  that  the  changes  and  additions  that 
appear  in  this  new  edition  will  add  materially  to  the  usefulness  of  the 

Finally,  the  writer  wishes  to  express  his  appreciation  of  the  very 
kind  reception  accorded  this  book  by  the  Profession,  without  which 
this  revision  would  have  been  impossible. 

New  York  City. 



In  this  volume  the  writer  has  endeavored  to  bring  together  and 
arrange  in  a  manner  easily  accessible  for  reference  a  large  number  of 
procedures  employed  in  diagnosis  and  treatment.  The  book  has  been 
given  the  comprehensive  title  "Diagnostic  and  Therapeutic  Technic." 
The  scope  of  the  work,  however,  can  be  best  appreciated  by  consulting 
the  table  of  contents  on  page  xi. 

While  some  of  the  methods  herein  detailed  belong  essentially  to  the 
domain  of  the  specialist,  the  majority  are  the  e very-day  practical  proce- 
dures which  the  hospital  interne  or  the  general  practitioner  may  at  any 
time  be  called  upon  to  perform.  So  far  as  the  writer  is  aware  there  is  no 
single  book  to  which  one  may  turn  for  information  along  these  lines. 
Text-books  of  the  present  day,  treating  exhaustively  as  they  do  of  the 
larger  problems  of  medicine  and  surgery,  must  of  necessity,  if  they 
are  to  be  kept  within  reasonable  limits,  omit  or  else  describe  in  a  most 
condensed  manner  these  so-called  minor  procedures.  If  the  reader 
desires  fuller  and  more  detailed  information  it  not  infrequently  happens 
that  it  is  necessary  for  him  to  consult  a  number  of  works  before  he 
obtains  all  the  desired  information.  To  supply  such  a  want  is  the 
object  of  this  book. 

The  plan  of  the  work  comprises,  first,  a  description  of  certain 
general  diagnostic  and  therapeutic  methods  and,  second,  a  description 
of  those  measures  employed  in  the  diagnosis  and  treatment  of  diseases 
affecting  special  regions  and  organs  of  the  body.  Operative  methods 
have  been  omitted  as  far  as  possible,  only  those  having  been  considered 
which  are  required  in  emergencies  or  which  form  a  necessary  part  of 
some  of  the  measures  described.  Each  procedure  has  been  given  in 
detail,  leaving  nothing  to  the  reader's  imagination.  For  this  reason, 
and  that  each  section  might  be  complete  in  itself  without  referring  the 
reader  to  other  portions  of  the  text,  some  unavoidable  repetition  occurs. 

All  important  steps  have  been  illustrated  so  that  the  reader  may 
grasp  at  a  glance  the  technic  of  the  various  procedures,  no  expense 
having  been  spared  in  this  direction.  Nearly  all  the  illustrations  are 
line  drawuigs  made  by  Mr.  John  V.  Alteneder,  head  of  the  W.  B. 


Saunders'  art  department,  from  photographs  under  the  author's  super- 
Wsion.  The  excellence  and  high  character  of  his  work  has  done  much 
to  elucidate  the  text.  In  instances  where  illustrations  from  other 
sources  have  been  utilized  due  credit  has  been  given. 

I  desire  here  to  express  my  heartiest  thanks  to  my  father,  Dr. 
Prince  A.  Morrow,  and  to  Drs.  T.  J.  Abbott,  J.  M.  Lynch,  J.  H.  Potter, 
and  J.  F.  McCarthy  for  many  valuable  suggestions  and  criticisms,  and 
to  others  who  have  assisted  me  in  various  ways  in  the  preparation  of  the 

My  thanks  are  also  due  the  Kny-Scheerer  Co.,  of  New  York,  for 
ha\ang  kindly  furnished  many  of  the  instruments  from  which  drawings 
have  been  made. 

A.  S.  M. 

New  York  City. 




The  Administration  of  General  Anesthetics i 

Preparations  of  the  patient  for  general  anesthesia 2 

Stages  of  anesthesia 6 

Ether  anesthesia 8 

Chloroform  anesthesia 17 

Nitrous  oxid  anesthesia 23 

Nitrous  oxid  and  oxygen  anesthesia 27 

Nitrous  oxid  and  ether  sequence 28 

Ethyl  chlorid  anesthesia 30 

Anesthetic  mixtures 33 

Intubation  anesthesia 34 

Intratracheal  insufflation  anesthesia •.    .  36 

Anesthesia  through  a  tracheal  opening 40 

Intravenous  general  anesthesia 41 

Rectal  anesthesia .  44 

Oil-ether  colonic  anesthesia 47 

Scopolamin-morphin  anesthesia   . 48 

Accidents  during  anesthesia  and  their  treatment 48 

After-effects  of  anesthetics 55 

After-treatment  of  cases  of  general  anesthesia 57 


Local  Anesthesia 59 

Advantages  and  disadvantages  of  local  anesthesia 60 

Methods  of  producing  local  anesthesia 63 

Drugs  employed  for  local  anesthesia 64 

Preparation  of  patient  for  local  anesthesia 67 

Conduction  of  an  operation  under  local  anesthesia 68 

Local  anesthesia  by  cold 69 

Surface  application  of  anesthetic  drugs ' 70 

Infiltration  anesthesia 71 

Endo-  and  perineural  infiltration 76 

Practical  application  of  infiltration,  endo-  and  perineural  methods  of  anes- 
thesia to  special  localities 78 

Operations  on  inflamed  tissues  under  local  anesthesia 92 

Bier's  venous  anesthesia 93 

Arterial  anesthesia 97 

Spinal  anesthesia 98 

Sacral  anesthesia 105 


Sphygmomanometry 109 

Normal  blood-pressure no 




Instruments  for  estimating  blood-pressure iii 

Technic  of  estimating  blood-pressure 114 

Variations  of  blood-pressure  in  disease 116 


Transfusion  of  Blood 119 

Indications  and  contraindications 120 

Hemolysis 121 

Selection  of  the  donor 121 

Artery  to  vein  transfusion 121 

Technic  by  Crile's  method 125 

Brewer's  method 127 

Hartwell's  method 128 

Levin's  method 128 

Elsberg's  method 129 

Technic  by  Carrel's  suture 129 

Vein  to  vein  transfusion 131 

Injections  of  Human  Blood  Serum 132 


Infusions  of  Physiological  Salt  Solution  135 

Indications 135 

Preparation  of  normal  salt  solution 136 

Artificial  sera  for  infusions 137 

Intravenous  infusion 138 

Intraarterial  infusion 144 

Hypodermoclysis 148 

Rectal  infusion 151 


Acupuncture 152 

Venesection 153 

vScarification 158 

Subcutaneous  Drainage  for  Edema 160 

Cupping 162 

Leeching 166 


Hypodermic  and  Intramuscular  Injection  of  Drugs 170 


Administration  of  Diphtheria  Antitoxin 183 

Vaccination 188 


The  Treatment  of  Neuralgia  by  Injections 194 

Trifacial  neuralgia 194 

Sciatica 200 




Bier's  Hyperemic  Treatment 203 

Passive  hyperemia 203 

Effects  of  h3^peremia 204 

Indications 206 

General  principles  underlying  hyperemic  treatment 207 

Passive  hyperemia  by  means  of  constricting  bands. 209 

Passive  hyperemia  by  means  of  suction  cups 215 

Active  hyperemia 220 

The  Diagnosis  and  Treatment  of  Fistulous  Tracts  by  IMeans  of  Bismuth 

Paste 223 


Collection  and  Preservation  of  Pathological  ^Material 227 

Method  of  making  smear  preparations  for  microscopical  examination.     .  227 

Method  of  inoculating  culture  tubes 235 

Collection  of  discharges  and  secretions  for  bacteriological  examination    .  238 

Collection  of  blood  for  microscopical  examination 245 

Collection  of  blood  for  bacteriological  examination 250 

Collection  of  sputum 252 

CoUection  of  urine 252 

Collection  of  stomach  contents. 254 

CoUection  of  feces 254 

Removal  of  a  fragment  of  solid  tissue  for  examination 254 


Exploratory  Punctures ^58 

Exploratori'  punctures  in  general 258 

Exploratory  puncture  of  the  pleura 259 

Exploratory  puncture  of  the  lung 264 

Exploratory  puncture  of  the  pericardium 265 

Exploratory  puncture  of  the  peritoneal  cavit}" 268 

Exploratory  puncture  of  the  liver 269 

Exploratory  puncture  of  the  spleen 271 

Exploratory  puncture  of  the  kidneys 273 

Exploratory  puncture  of  joints 274 

Spinal  puncture 277 

Spinal  puncture  as  a  means  of  administering  antitoxic  sera 283 



Aspiration  of  the  pleural  cavity 285 

Aspiration  of  the  pericardium 293 

Aspiration  of  the  abdomen  for  ascites 296 

Aspiration  of  the  tunica  vaginalis 300 

Aspiration  of  the  bladder 303 


The  Nose  and  Accessory*  Sinuses 304 

Anatomic  considerations. 304 



Diagnostic  methods 309 

Rhinoscopy 309 

Inspection  of  the  nasopharynx  l)y  means  of  Hays'  pharyngoscope    .    .    .317 

Palpation  by  the  probe 319 

Digital  palpation  of  the  nasopharynx 322 

Transillumination  of  the  accessory  sinuses 323 

Skiagraphy 325 

Therapeutic  measures 325 

Nasal  douching 325 

The  nasal  syringe 329 

The  nasal  spray 330 

Direct  application  of  remedies 332 

Insufflations 334 

Lavage  of  the  accessory  sinuses 336 

Passive  hyperemia  in  diseases  of  the  nose  and  accessory  sinuses   ....  343 

Tamponing  the  nose  for  the  control  of  hemorrhage 343 


The  Ear 348 

Anatomic  considerations 348 

Diagnostic  methods 352 

Direct  inspection 354 

Otoscopy 355 

Determination  of  the  mobility  of  the  drum  membrane 359 

Hearing  tests 360 

Inflation  of  the  middle  ear  for  diagnosis 363 

Therapeutic  measures 370 

The  ear  syringe 370 

Instillations 373 

Application  of  caustics 375 

Inflation  of  the  middle  ear  for  therapeutic  purposes 376 

Inflation  with  medicated  vapors 376 

Injection  of  solutions  into  the  Eustachian  tubes 377 

The  Eustachian  bougie 378 

Massage  of  the  drum  membrane 380 

Incision  of  the  drum  membrane 381 


The  Larynx  and  Trachea 385 

Anatomic  considerations 385 

Diagnostic  methods 389 

Laryngoscopy  and  tracheoscopy 389 

Direct  laryngoscopy 396 

Autoscopy 399 

Direct  tracheo-bronchoscopy 400 

Palpation  by  the  probe 407 

Skiagraphy 408 

Therapeutic  measures 408 

The  laryngeal  spray 408 

Direct  application  of  remedies 409 

Insufflations 411 

Steam  inhalations 412 



Dry  inhalations 4^5 

Intubation 4i5 

Tracheotomy 424 


The  Esophagus 435 

Anatomic  considerations 435 

Diagnostic  methods 43° 

Auscultation 437 

Percussion 437 

Palpation 437 

Examination  by  sounds  and  bougies 437 

Esophagoscopy 445 

Skiagraphy 449 

Therapeutic  measures 449 

Lavage  of  the  esophagus •    •   449 

Dilatation  of  esophageal  strictures  by  the  bougie 45 1 

Intubation  of  the  esophagus 45^ 


The  Stomach ■ ■  46i 

Anatomic  considerations 461 

Diagnostic  methods    .• 462 

Inspection 464 

Palpation ■ ■    •  466 

Percussion 469 

Auscultation    .   ■ 47^ 

Inflation  of  the  stomach 47 1 

Extraction  of  stomach  contents  for  examination 474 

Test  of  motor  function 482 

Test  of  absorption  power 483 

Gastrodiaphany 483 

Gastroscopy 485 

Skiagraphy 493 

Exploratory  laparotomy 493 

Therapeutic  measures 494 

Lavage  of  the  stomach 494 

The  stomach  douche 499 

Gavage 502 

Duodenal  feeding 505 

Massage 5^7 

Electrotherapy 509 


The  Colon  and  Rectum 5^3 

Anatomic  considerations 5^3 

Diagnostic  methods 5^7 

I.  Abdominal  Examination 518 

Inspection 5^8 

Palpation 5^9 

Percussion ■ 520 



Auscultation 520 

Inflation  of  the  colon 521 

Skiagraphy 524 

II.  Internal  Examination 524 

Inspection 526 

Palpation  by  the  finger 527 

Manual  palpation 529 

Examination  by  the  speculum  or  proctoscope 530 

Examination  by  sounds  and  bougies 537 

Examination  by  the  bougie  a  boule 538 

Examination  by  the  probe 539 

Lavage  of  the  bowel 540 

Examination  of  the  feces 541 

Therapeutic  measures 541 

Enemata 541 

Enteroclysis 546 

Saline  rectal  infusion 554 

Continuous  proctoclysis 556 

Nutrient  enemata 560 

Injection  of  fluids  or  air  into  the  bowel  in  intussusception 563 

Dilatation  of  rectal  strictures  by  the  bougie 565 

Colonic  massage 568 

Auto-massage 570 

Application  of  electricity  to  the  rectum  and  colon 571 


The  Urethra  and  Prostate 574 

Anatomic  considerations 574 

Diagnostic  methods 578 

Glass  tests  for  locating  urethral  pus 579 

Injection  test  for  locating  urethral  pus 581 

Inspection 581 

Palpation 582 

Examination  by  sounds  and  bougies 585 

Examination  by  the  bougie  a  boule 594 

Urethrometry 596 

Estimation  of  the  urethral  length 597 

Urethroscopy  in  the  male 598 

Urethroscopj'^  in  the  female 605 

Therapeutic  measures *.    .    .  607 

Urethral  injections 607 

Irrigations  of  the  urethra 611 

Instillations 616 

Application  of  ointments 618 

Urethroscopic  treatment 620 

Direct  application  of  cold  to  the  urethra 622 

Prostatic  massage 624 

Meatotomy 626 

Treatment  of  strictures  by  gradual  dilatation 627 

Treatment  of  strictures  by  continuous  dilatation 640 




The  Bladder 642 

Anatomic  considerations 642 

Diagnostic  methods 644 

Urinalysis 646 

Inspection 650 

Percussion 651 

Palpation 651 

Sounding  for  stone 653 

Test  of  bladder  capacity 657 

Estimation  of  residual  urine 658 

Test  for  absorption  from  the  bladder 659 

Cystoscopy  in  the  male 659 

Cystoscopy  in  the  female ; 665 

Skiagraphy 671 

Therapeutic  measures 671 

Irrigations 671 

Auto-irrigations 675 

Instillations 676 

Cystoscopic  treatment 677 

The  destruction  of  vesical  growths  by  the  high  frequency  current    .    .    .  678 

Catheterization  in  the  male 680 

Catheterization  in  the  female 687 

Continuous  catheterization 689 

Aspiration  of  the  bladder 692 


The  Kidneys  and  Ureters 695 

Anatomic  considerations 695 

Diagnostic  methods 698 

Inspection 698 

Palpation  of  the  kidney 699 

Palpation  of  the  ureters 701 

Percussion 703 

Urinalysis 704 

Catheterization  of  the  ureters  in  the  male 705 

Catheterization  of  the  ureters  in  the  female 714 

Pyelometry 720 

Segregation  of  urine •  .  721 

Determination  of  the  functional  capacity  of  the  kidneys 725 

Skiagraphy 730 

Pyelography 731 

Exploratory  incision 731 

Therapeutic  measures 732 

Medication  of  the  renal  pelvis  and  ureters 732 

Dilatation  of  ureteral  strictures 733 


The  Female  Generatwe  Organs 735 

Anatomic  considerations 735 

Diagnostic  methods 737 


I.  Examination  of  the  abdomen. 

Inspection , 742 

Palpation 743 

Percussion • 745 

Auscultation 747 

Mensuration 747 

II.  Examination  of  the  pelvic  organs. 

Inspection 748 

Examination  of  discharges 749 

Digital  palpation 750 

Bimanual  palpation 752 

Examination  by  means  of  specula 759 

Sounding  the  uterus 764 

Digital  palpation  of  the  uterine  cavity 766 

Examination  of  sections  and  scrapings  from  the  uterus 768 

Exploratory  vaginal  incision 768 

Therapeutic  measures 771 

Vaginal  irrigations 77 1 

Local  applications  to  the  vagina  and  cervix 774 

Application  of  powders  to  the  vagina 775 

Vaginal  tampons 776 

Intrauterine  douche 779 

Intrauterine  applications 783 

Tamponing  the  uterus 786 

Bier's  hyperemic  treatment  in  gynecology 789 

Pelvic  massage 789 

Scarification  of  the  cervix 791 

Pessary  therapy 792 

Dilatation  of  the  cervix 803 

Curettage 807 

Index 81 


Diagnostic  and  Therapeutic 


The  term  anesthesia  denotes  a  condition  of  insensibility  to  pain 
and  an  anesthetic  is  any  agent  which  produces  such  a  condition. 
Anesthetics  are  divided  into  general  and  local.  The  drugs  most 
used  for  general  anesthesia  are  ether,  chloroform,  nitrous  oxid  gas, 
and  ethyl  chlorid  administered  separately,  in  sequence,  or  in  combina- 
tion with  one  another. 

The  choice  of  the  anesthetic  agent  and  the  decision  as  to  the 
method  of  its  administration  are  questions  of  vital  importance. 
Under  any  general  anesthetic  the  patient  is  brought  practically  to  the 
border-line  between  life  and  death,  and,  in  many  cases,  the  life  of  the 
patient  depends,  in  the  first  place,  upon  the  selection  of  the  anesthetic, 
and,  in  the  second  place,  upon  the  way  in  which  it  is  administered. 
While  the  safety  of  the  patient  should  always  be  the  first  consideration 
and  the  main  guide  in  the  choice  of  the  anesthetic,  it  is  unfortunately 
impossible  to  lay  down  any  hard  and  fast  rules.  Each  case  must  be 
studied  separately,  and  the  anesthetic  chosen  that  is  best  suited  to 
that  particular  case.  The  production  of  narcosis  with  the  same 
anesthetic  under  all  conditions,  even  though  the  particular  agent 
chosen  were  statistically  safe,  would  certainly  be  unjustifiable.  An 
anesthetic  that  could  be  used  with  safety  under  some  conditions  would 
be  a  menace  to  life  under  others.  The  condition  of  the  patient,  the 
nature  of  the  operation,  the  anesthetist,  and  the  operator  himself  are 
all  factors  that  enter  into  consideration.  Furthermore,  in  estimating 
the  relative  safety  of  the  different  anesthetics,  one  must  consider  not 
only  the  immediate  dangers,  but  also  the  more  remote  toxic  effects 
that  frequently  do  not  appear  until  some  time  later.  No  general 
rules  will  be  laid  down  at  this  time  as  to  the  selection  of  the  anes- 
thetic, but  in  considering  each  agent  an  attempt  will  be  made  to 
indicate  the  cases  for  which  it  is  best  suited. 


Preparations  for  Anesthesia  and  Precautions. — A  certain  amount 
of  preparation  of  the  patient  is  necessary  before  the  administration  of 
a  general  anesthetic.  Experience  teaches  that  the  patient  takes  an 
anesthetic  better  if  he  be  placed  upon  a  light  but  nutritious  diet  for 
several  days  before  operation,  and  the  bowels  be  properly  regulated. 
In  some  special  cases  it  ma}'  be  necessary  to  subject  the  patient  to  a 
very  careful  regime,  beginning  even  some  weeks  before  operation  in 
order  to  put  him  in  the  best  possible  condition.  In  other  cases  where 
only  a  light  anesthesia — as  from  nitrous  oxid — is  required,  but  little 
preparation  will  be  necessary. 

Care  of  the  Bowels. — When  possible,  the  intestinal  canal  should 
be  emptied  a  number  of  hours  before  anesthetization.  The  usual 
custom  is  to  give  a  purge,  consisting  of  castor  oil,  calomel,  compound 
licorice  powder,  or  magnesium  sulphate,  the  night  before  the  opera- 
tion, followed  by  a  soapsuds  enema  in  the  morning.  Often,  however, 
the  nature  of  the  operation  or  lack  of  time  does  not  permit  of  the 
administration  of  cathartics.  In  such  cases,  a  purgative  enema  is 
relied  upon. 

Diet. — The  diet  for  twenty-four  hours  before  the  operation  should 
be  of  an  easily  digestible  character,  and  should  be  taken  in  small 
amounts  to  prevent  overloading  the  alimentary  canal.  If  the  opera- 
tion is  set  for  earh-  in  the  morning,  no  food  should  be  given  after  a 
light  supper  the  previous  night;  if  it  is  fixed  for  the  afternoon,  a  very 
light  breakfast  may  be  taken,  not  later  than  8  a.m.  A  feeling  of 
faintness  or  weakness  may  necessitate  the  giving  of  a  cup  of  hot 
broth  or  beef  tea  even  later  than  this  in  some  cases,  but  it  should  be  a 
general  rule  not  to  give  any  food  by  mouth  within  three  hours  of 
the  time  for  anesthesia,  since,  if  the  stomach  is  not  empty  at  the  time 
of  operation,  vomiting  is  almost  sure  to  occur,  adding  not  only  to  the 
dajiger  of  the  anesthetic,  but  to  the  subsequent  distress  of  the  patient. 
In  some  cases  of  special  gravity  on  account  of  shock  or  marked 
feebleness,  a  nutrient  enema  (see  page  58),  with  the  addition  of 
whisky  or  brandy,  may  be  given  half  an  hour  before  the  anesthesia 
is  commenced. 

In  an  emergency,  lavage  of  the  stomach  may  be  performed  when 
a  full  meal  has  been  taken  shortly  before.  Preliminary  washing  out 
of  the  stomach  will  be  required  when  that  organ  is  the  seat  of  opera- 
tion; it  should  also  be  practised  if  a  general  anesthetic  is  to  be  admin- 
istered when  intestinal  obstruction  with  vomiting  is  present,  for,  in 
such  cases,  patients  have  been  known  to  fairly  drown  from  the  con- 
tents of  the  stomach  suddenly  pouring  out  under  the  relaxation  of  the 


anesthetic.  To  avoid  undue  excitement  and  possible  collapse,  the 
lavage  may  be  performed  just  as  the  patient  is  under  complete 

Preparation  of  the  Mouth,  Teeth,  Etc. — Preparation  of  the  nose, 
mouth,  and  teeth  lessens  the  dangers  of  aspiration  pneumonia  and 
septic  bronchitis.  As  a  rule,  cleansing  the  nose  and  mouth  with  an 
antiseptic  solution  and  thoroughly  brushing  the  teeth  is  sufficient, 
but,  in  some  instances,  the  neglect  of  the  teeth  results  in  a  very  foul 
and  septic  condition,  necessitating  systematic  treatment  for  several 
days  before  the  anesthetic  can  safely  be  administered. 

The  Preliminary  Use  of  Drugs. — A  good  night's  rest  does  much  to 
fortify  the  patient  and  put  him  in  the  best  possible  condition  for  the 
operation.  With  some  patients  simply  a  rub-down  with  alcohol  at 
bedtime  sufiices  to  induce  sleep;  for  others,  especially  if  nervous,  the 
administration  of  trional  or  the  bromids  is  indicated. 

Many  surgeons  administer  morphin  hypodermically  before  anes- 
thesia. In  some  cases  this  is  of  advantage,  shortening  the  stage  of 
excitement  and  necessitating  less  of  the  anesthetic  to  maintain  insen- 
sibility, but  it  should  not  be  a  routine  practice.  In  highly  excitable, 
vigorous,  alcoholic  individuals  it  is  of  distinct  advantage.  With  its 
use,  however,  it  is  necessary  to  maintain  lighter  anesthesia  than 
without  it.  The  chief  objection  to  morphin  is  that  it  depresses 
respiration  and,  by  its  action  upon  the  pupils,  may  mask  symptoms  of 
overnarcosis;  furthermore,  it  delays  the  awakening  from  the  anes- 
thesia. In  children  or  the  very  old  it  must  be  used  with  caution. 
Any  condition  producing  embarrassed  or  obstructed  respiration  is 
a  contraindication  as  is,  of  course,  any  idiosyncrasy  against  the  drug. 
It  should  not  be  given  to  very  weak  subjects  or  to  those  in  stupor. 

By  some  operators  atropin  gr.  i/ioo  (0.00065  gm.)  is  given  half 
an  hour  before  the  anesthetic  is  started  as  a  routine  procedure  for 
the  purpose  of  suppressing  the  secretion  in  the  upper  air  passages 
and  bronchi,  thus  lessening  irritation  of  the  respiratory  mucous 

Physical  Examination. — A  thorough  physical  examination  should 
be  made  in  all  cases  as  a  routine  preHminary  to  general  anesthesia,  for 
exact  knowledge  as  to  the  state  of  health  is  essential  to  an  intelligent 
selection  of  the  anesthetic  and  its  safe  administration.  Such  an 
examination  has  a  good  moral  effect  upon  the  patient,  and,  if  assur- 
ance can  be  given  that  nothing  abnormal  can  be  discovered,  it  does 
much  to  allay  the  natural  fear  and  timidity  of  a  nervous  individual. 
This  examination  should  include  a  record  of  the  pulse,  temperature. 


and  respirations,  a  physical  examination  of  the  heart,  arteries,  and 
lungs,  and  a  blood  and  urine  examination,  and  should  be  made,  when 
possible,  before  the  day  of  operation,  so  that  if  the  results  of  the 
examination  demand  it,  the  operation  may  be  postponed  without 
subjecting  the  patient  to  unnecessary  preparations.  In  the  presence 
of  acute  bronchitis  or  coryza,  a  postponement  of  the  anesthesia  is 
advisable.  Chronic  bronchitis,  however,  is  sometimes  improved  by 
an  anesthetic.  Heart  disease,  with  good  compensation,  is  not  a 
contraindication  to  general  anesthesia. 

The  urine  should  always  be  examined  if  the  case  is  such  that  time 
allows,  noting  the  total  amount  for  twenty-four  hours,  the  specific 
gravity,  and  the  amount  of  urea,  and  making  tests  for  albumin,  sugar, 
etc.,  as  well  as  a  microscopical  examination  for  casts.  The  quantity 
of  urea  eliminated  within  twenty-four  hours  is  especially  important. 
A  normal  adult  male  will  pass  250  to  450  gr.  (16  to  29  gm.),  and 
females  less.  If  the  quantity  eliminated  falls  much  below  this  normal 
minimum,  the  operator  should  be  put  on  his  guard,  and,  when  the 
total  urea  falls  below  100  gr.  (6.5  gm.),  no  one  can  safely  be  given  a 
general  anesthetic  (Fowler).  If  albumin  be  present,  the  dangers  of  a 
general  anesthetic  are  increased,  especially  wdth  ether.  In  the  pres- 
ence of  large  quantities  of  albumin  and  casts  the  operation  should  be 
postponed  or  local  anesthesia  substituted.  With  sugar  in  the  urine, 
the  chances  of  diabetic  coma  developing  should  be  carefully  con- 
sidered. The  presence  of  acetone  and  diacetic  acid  is  of  especial 
dangerous  significance. 

Another  important  point  is  the  arterial  tension.  When  time  per- 
mits, the  blood-pressure  should  be  taken  in  all  cases  (see  Chapter 
III).  If  it  is  found  to  be  abnormally  high,  nitrites  should  be  admin- 
istered for  several  days,  and,  where  there  is  not  time  for  this,  nitro- 
glycerin should  be  given  by  hj-podermic  before  the  anesthetic  is 
begun.  In  the  presence  of  hypotension,  cardiac  stimulants  for  sev- 
eral days  previous  to  the  operation  are  indicated. 

Care  of  the  Patient. — While  the  patient  is  on  the  operating-table 
care  should  be  taken  to  maintain  the  bodily  heat  and  prevent  chilHng 
by  a  proper  amount  of  covering.  The  habit  of  washing  patients  with 
quarts  of  solution  and  leaving  them  lying  in  a  pool  of  chilly  water  is 
to  be  condemned.  It  is  preferable  to  arrange  the  patient  upon  the 
table  before  the  anesthetic  is  begun.  Anesthetizing  a  patient  in  one 
room  and  then  moving  him  to  the  operating-room  is  not,  as  a  rule, 
advisable;  the  lifting  around  of  the  patient  allows  him  to  partly  come 
out,  and  often  starts  up  vomiting. 


The  position  assumed  by  the  patient  upon  the  operating-table 
should  be  unconstrained  and  as  comfortable  as  is  consistent  with  the 
needs  of  the  case.  A  supine  position,  ^\'ith  the  head  elevated  suffi- 
ciently upon  a  small  pillow  to  allow  freedom  in  breathing,  answers  in 
the  majority  of  cases.  Ether  and  nitrous  oxid  may  be  given  with  the 
patient's  head  and  trunk  elevated,  but  great  caution  should  be 
observed  in  administering  chloroform  to  a  patient  sitting  up  or  semi- 
upright,  on  account  of  the  danger  of  cerebral  anemia.  In  weak 
anemic  individuals  the  upright  position  should,  for  the  same  reasons, 
be  avoided  with  anv  anesthetic. 

Fig.  I. — The  anesthetist's  supphes.  i,  Pus  basin;  2,  mouth  wipes  on  artery 
clamps;  3,  mouth  wedge;  4,  tongue  forceps;  5,  mouth  gag;  6,  hypodermic 

Before  administering  the  anesthetic,  anything  that  interferes  with 
or  obstructs  the  respiration  in  the  shghtest  degree  should  be  removed. 
Tight  collars,  bandages  about  the  neck,  clothing,  belts,  straps,  braces, 
etc.,  should  invariably  be  loosened,  no  matter  how  short  the  anes- 
thesia. The  mouth  should  be  examined,  and  false  teeth,  obturators, 
plates,  chewing  gum.  tobacco,  etc.,  should  be  removed  lest  they  fall 
back  into  the  larynx  and  cause  choking.  No  noise  or  talking  should 
be  permitted  in  the  anesthetic  room.  It  is  always  well  to  have  a 
third  person  present  in  case  help  is  needed,  and  in  the  case  of  a  female 
patient  this  is  very  necessary,  as  erotic  dreams  may  lead  to  damaging 
accusations  against  the  anesthetist. 

The  Anesthetist'' s  Supplies. — Besides  the  apparatus  necessary  for 
the  actual  administration  of  the  anesthetic,  the  anesthetist  should 
be  provided  with  the  following:  a  mouth  gag,  a  wedge  or  screw- 


shaped  piece  of  hard  rubber  to  force  the  jaws  apart,  tongue  forceps, 
a  hypodermic  syringe  in  good  working  order,  with  whisky,  camphor, 
adrenalin,  atropin,  and  strychnin  at  hand,  a  number  of  small  mouth 
wipes  with  an  artery  clamp  as  a  holder,  and  a  small  pus  basin 
(Fig.  i).  A  cylinder  of  oxygen  should  be  ready  for  use,  and  an 
infusion  set  and  tracheotomy  tube  should  be  accessible. 

Duration  of  Anesthesia. — The  anesthetic  should  be  administered 
no  longer  than  is  absolutely  necessary.  It  should  not  be  started  until 
everyone,  including  the  surgeon  and  his  assistants,  is  nearly  ready, 
and  the  completion  of  the  anesthesia  should  be  so  timed  that  the 
patient  is  coming  out  of  it  when  he  leaves  the  table. 

Fig.  2. — Arrangement  of  the  operating-table  and  the  anesthetist's  supplies. 

Stages  of  Anesthesia. — Anesthesia  from  most  of  the  general  anes- 
thetics passes  through  four  stages:  (i)  The  initial,  or  stage  of  irri- 
tation; (2)  the  stage  of  excitement;  (3)  the  stage  of  surgical 
anesthesia;  and  (4)  the  stage  of  coming  out.  With  some  anes- 
thetics the  early  stages  may  be  more  or  less  modified,  or  entirely  ab- 
sent, and  the  rapidity  with  which  the  patient  passes  through  the 
different  stages  depends  upon  the  drug  employed  and  the  technic  of 
its  administration. 

The  Initial  Stage. — The  inhalation  of  anesthetics  like  ether  or 
chloroform  produces  irritation  of  the  mucous  membrane  of  the  respir- 
atory tract  and  a  profuse  secretion  of  mucus  with  some  coughing  and 
frequent  acts  of  swallowing.     To  some  persons,  the  odor  and  taste  of 


the  anesthetic  are  exceedingly  unpleasant,  so  that  temporary  holding 
of  the  breath  is  not  uncommon.  If  the  vapor  is  given  in  too  concen- 
trated a  form,  violent  coughing  will  be  induced,  accompanied  by 
cyanosis,  and  frequently  a  sense  of  suffocation  is  experienced  and  the 
patient  tries  to  tear  off  the  mask.  If  given  slowly,  the  coughing 
passes  off  and  the  respirations  become  rapid  and  regular.  Spots 
appear  before  the  eyes  and  the  patient  becomes  drowsy.  A  flushed 
face,  rapid  and  full  pulse,  with  hurried  respirations  are  characteristic 
of  this  stage.  The  pupils  dilate,  but  react  to  light,  and  the  cornea 
responds  to  touch.  In  this  stage  the  reflexes  are  increased,  so  that 
a  painful  examination  or  sudden  shock  is  dangerous. 

The  Stage  of  Excitement. — Following  this  preliminary  stage,  the 
patient  rapidly  passes  into  a  condition  of  excitement  or  intoxication. 
His  speech  becomes  incoherent,  and  often  the  imagination  is  excited 
and  hallucinations  occur.  The  patient  begins  to  struggle,  throws  his 
arms  about,  kicks,  tries  to  tear  off  the  mask,  and  frequently  laughs, 
sings,  yells,  cries,  moans,  or  swears.  He  may  breathe  deeply  and 
rapidly,  or  hold  his  breath  and  refuse  to  breathe,  so  that  he  becomes 
markedly  cyanotic.  The  jaws  are  often  held  together  tightly  by  a 
spasm  of  the  masseter  muscles.  Contractions  of  the  muscles  of  the 
trunk  and  extremities  occur.  The  eyes  are  often  rolled  from  side  to 
side.  While  the  patient  usually  hears  those  around  him  talking, 
he  fails  to  understand  what  is  said.  Consciousness  and  sensation  are 
gradually  diminished.  The  pupils  are  still  dilated.  The  pulse  is 
rapid  and  full,  with  very  marked  pulsations  in  the  large  vessels  of  the 

Stage  of  Surgical  Anesthesia. — Following  this  period  of  rigidity 
and  excitement,  comes  one  of  general  relaxation.  The  contracted 
muscles  relax;  the  pulse  becomes  slower  and  regular;  the  breathing 
becomes  more  superficial  and  less  hurried,  and  is  accompanied  by  a 
deep  snoring  due  to  the  relaxation  of  the  soft  palate.  The  pupils 
contract  but  still  react  slowly  to  light,  and  the  conjunctival  reflex 
disappears.  The  skin  becomes  cool,  pale,  and  moist.  Total  insen- 
sibility is  now  produced,  and  the  anesthesia  is  complete.  The  loss  of 
the  conjunctival  reflex  is  taken  as  a  sign  that  unconsciousness  is 
present.     This  is  the  time  for  operation. 

The  guide  to  the  depth  of  anesthesia  after  the  disappearance  of 
the  conjunctival  reflex  is  the  condition  of  the  pupils.  With  light 
anesthesia,  the  pupils  are  moderately  contracted  and  readily  react  to 
light;  under  deeper  anesthesia,  the  pupils  are  contracted  and  fail  to 
react  to  light;  and  when  a  very  profound  and  dangerous  stage  of 


anesthesia  is  established,  the  pupils  dilate  widely  and  remain  so 
without  reaction  to  light,  and  the  respirations  become  shallow  and 
gasping.  In  the  early  stages  of  anesthesia,  and  when  the  patient  is 
coming  out,  the  pupils  also  dilate,  but  they  still  react  to  light  and  the 
corneal  reflex  is  also  present.  After  complete  anesthesia  has  been 
once  reached,  it  may  be  readily  maintained  by  adding  small  amounts 
of  the  anesthetic  from  time  to  time;  just  enough  should  be  adminis- 
tered to  keep  the  pupils  midway  between  contraction  and  dilatation, 
with  a  response  to  Hght  at  all  times. 

Stage  of  Recovery. — The  recovery  from  the  anesthetic  is  character- 
ized by  the  occurrence  of  these  same  stages  in  reverse  order.  In 
some  cases  the  recovery  is  more  rapid  than  in  others.  The  breathing 
becomes  slower  and  less  audible,  and  there  is  frequent  sighing.  The 
conjunctival  reflex  reappears,  the  pupillary  reflex  becomes  active, 
and  the  patient  rolls  the  eyes  about.  Frequent  swallowing  occurs, 
followed  by  retching.  Vomiting  of  frothy  and  often  bile-stained 
mucus  is  present  in  most  cases,  and  may  be  continued  for  an  hour  or 
more.  Partial  consciousness,  wath  laughing,  crying,  or  incoherent 
speech  follow,  and  it  is  usually  some  hours  before  the  mental  equilib- 
rium is  completely  regained.  Hyperesthesia  is  marked  in  the  period 
of  recovery,  and  general  irritabiHty.  complaints  of  discomfort,  and 
pain  are  to  be  expected.  Some,  however,  especially  children,  pass 
nto  a  deep  sleep  lasting  for  several  hours. 


Ether  is  a  very  volatile,  colorless  liquid,  with  a  strong,  pungent 
odor  and  a  burning,  sweetish  taste.  It  is  very  inflammable,  and 
should  not  be  used  near  a  flame,  cautery,  or  an  X-ray  tube.  An 
artificial  light  held  well  above  it  is  safe,  however,  as  the  ether  fumes 
tend  to  sink  downward.  Only  the  purest  ether  should  be  used  for  an- 
esthetic purposes,  and  it  should  be  kept  in  hermetically  sealed  tin 
cans,  as  exposure  to  hght  and  air  cause  it  to  decompose  into  acetic 
acid  and  other  irritating  products. 

Ether  fumes,  when  inhaled,  prove  very  irritating  to  the  mucous 
membranes  of  the  nose,  mouth,  and  respiratory  tract,  and  produce 
an  increased  secretion  of  mucus  and  sahva,  often  accompanied  by 
coughing.  Lesions  of  the  lungs  are  thus  apt  to  follow  its  use,  and  may 
be  due  to  the  aspiration  of  saHva  as  well  as  to  the  direct  irritation  of 
the  ether  vapor.  Ether  is  a  distinct  cardiac  stimulant,  accelerating 
the  heart  action  and  raising  blood-pressure;  this  effect  is  well  shown 


when  ether  is  administered  to  a  very  ill  person,  the  character  of  the 
pulse  often  being  improved  immediately  and  continuing  so  until  the 
end  of  the  anesthesia.  While  its  primary  effect  is  one  of  stimulation, 
in  toxic  doses  it  acts  as  a  depressant,  especially  upon  the  respiratory 
centers.  It  is  estimated  that  ether  is  about  five  times  as  safe  as 
chloroform,  and,  as  it  is  less  rapid  in  its  action,  danger  signs  can  be  rec- 
ognized and  proper  treatment  instituted  with  more  chances  of  success 
than  with  the  latter.  Upon  the  kidneys  it  acts  as  an  irritant,  andpro- 
longed  anesthesia  often  results  in  postoperative  albuminuria.  Ether 
produces  a  distinct  leukocytosis,  a  slight  diminution  of  the  hemoglobin, 
and  a  marked  decrease  in  the  coagulation-time  of  the  blood  (Ham- 
burger and  Ewing).  According  to  Graham  the  phagocytic  power  of 
the  blood  is  reduced  after  an  ordinary  ether  anesthesia. 

Owing  to  its  low  boiling-point  and  volatility,  ether  is  very  rapidly 
eliminated  from  the  lungs,  and  it  is  necessary  to  give  it  in  a  more  or 
less  concentrated  form,  thus  differing  from  the  administration  of 
chloroform.  The  administration  of  ether  is  rendered  safer  if  prelimi- 
nary anesthesia  is  induced  by  some  quick  anesthetic,  as  nitrous  oxid 
or  ethyl  chlorid;  furthermore,  oxygen  and  ether  is  a  safer  mixture 
than  air  and  ether.  The  oxygen  may  be  administered  by  passing  the 
oxygen  tube  under  the  mask,  or,  in  the  closed  inhalers,  the  tube  may 
be  attached  directly  to  the  ether  bag. 

Suitable  Cases. — When  a  general  anesthetic  is  necessary  and  the 
operation  is  not  suited  to  nitrous  oxid  anesthesia,  ether  is  preferable 
to  chloroform  unless  direct  contraindications  to  its  use  are  present. 
In  the  hands  of  an  expert,  many  of  the  dangers  attributed  to  chloro- 
form are  absent,  but  it  must  be  remembered  that  under  the  same 
conditions  ether  is  also  less  dangerous.  In  unskilled  hands,  how- 
ever, there  can  be  no  doubt  that  ether  is  always  the  safer. 

For  the  stimulating  effects  in  cases  of  shock  or  hemorrhage,  or 
when  it  is  necessary  to  obtain  a  profound  degree  of  narcosis  with 
abohtion  of  the  reflexes,  ether  is  by  all  means  the  best  agent  to  use. 
In  anemia  ether  is  preferable  to  chloroform,  as  it  has  less  marked  an 
effect  upon  the  hemoglobin.  If  the  patient's  hemoglobin  is  below  30 
per  cent.,  however,  any  general  anesthetic  is  contraindicated  (Da 
Costa).  In  heart  disease,  if  the  compensation  is  good,  ether  is  safe, 
but  with  broken  compensation  or  when  there  is  high  arterial  tension 
and  degenerative  changes  in  the  blood-vessels,  it  is  contraindicated 
on  account  of  the  danger  from  overstimulation.  In  myocardial 
disease  it  is  unsafe,  but  not  so  dangerous  as  is  chloroform. 

On  account  of  its  irritant  action,   ether  should  be  avoided  in 



bronchitis  or  acute  lung  troubles,  and,  for  the  same  reason,  in 
advanced  Bright's  disease.  In  patients  over  sLxty  years  old,  ether, 
as  a  rule,  is  to  be  avoided,  as  they  are  very  likely  to  be  afflicted  with 
respiratory  troubles,  and  the  circulatory  system  is  usually  the  seat  of 
degenerative  changes.  For  children,  a  mixture  of  chloroform  and 
ether,  or  chloroform  alone,  is  the  better  anesthetic,  ether  proving 
irritating  to  the  delicate  respiratory  mucous  membrane  of  a  child, 
and  often  producing  such  a  flow  of  mucus  and  saliva  that  breathing  is 
seriously  interfered   with. 

Ether  is  not  recommended  in  cerebral  operations — at  the  begin- 
ning, at  any  rate — on  account  of  the  struggling,  resultant  conges- 
tion,   and   increased   liability    to   hemorrhage.     It   should   never   he 

Fig.  3. — The  Esmarch  mask. 

administered  in  operations  about  the  mouth  or  face  requiring  the  use 
of  a  cautery  near  by. 

Apparatus. — Ether  may  be  satisfactorily  administered  by  the  drop 
method,  the  semiopen,  the  closed,  or  the  vapor  method.  Different 
forms  of  inhalers  are  used,  according  to  which  method  is  employed. 
Of  the  open  inhalers,  any  of  the  chloroform  masks,  such  as  Esmarch's 
(Fig.  3)  or  Schimmelbusch's  (Fig.  4),  will  be  found  satisfactory. 
They  are  very  simple,  consisting  of  a  wire  frame  covered  with  canton 
flannel  or  several  layers  of  gauze,  upon  which  the  ether  is  dropped. 
Such  inhalers  permit  a  very  plentiful  supply  of  air.  An  ordinary 
chloroform  bottle  (Fig.  5)  may  be  used  for  the  dropping,  or  a  very 
convenient  dropper  may  be  improvised  by  cutting  a  groove  in 
opposite  sides  of  the  cork  of  the  ether  can — one  to  admit  air  and  the 
other  to  allow  the  escape  of  the  ether. 

The  Allis  inhaler  (Fig.  6)  is  a  type  of  the  semiopen  cone.     It 



consists  of  an  outer  rubber  case  in  the  upper  part  of  which  is  fitted 
a  metal  frame  provided  with  slits  through  which  is  threaded  a  cotton 
or  flannel  bandage.  A  very  simple  semiopen  inhaler  may  be  made  by 
rolling  several  thicknesses  of  heavy  brown  paper  into  a  cuff  and 

Fig.  4. — The  Schimmelbusch  mask. 

Fig.  5. — Chloroform  dropper. 

covering  it  with  a  towel.  The  top  of  the  cone,  which  is  held  partly 
closed  by  safety  pins,  is  filled  with  gauze  upon  which  the  ether  is 
poured  (Fig.  7). 

There  are  many  excellent  closed  inhalers,   such  as  the  Clover 
(Fig.  8),  the  Bennet  (Fig.  9),  the  Gwathmey,  the  Pedersen,  etc.  These 

Fig.  6.— The  AlHs  inhaler. 

consist  essentially  of  a  metal  face-piece  surrounded  by  an  inflatable 
rubber  rim,  an  ether  chamber  filled  with  gauze,  and  a  closed  rubber 
bag  into  and  out  of  w^hich  the  patient  breathes.  They  are  also  pro- 
vided with  suitable  openings  for  the  entrance  of  air.^     With  such 

1  Space  does  not  permit  a  detailed  description  of  these  inhalers,  nor  is  it  necessary, 
as  a  description  of  the  mechansim  and  full  instructions  are  furnished  with  each 



inhalers,  the  temperature  of  the  ether  vapor  is  raised  by  the  expired 
air  and  the  supply  of  carbon  dioxid,   the  normal  stimulant  of  the 
respiratory  and  cardio-vascular  centers,  is  maintained  through  the 
rebreathing,  thus  adding  to  the  value  and  safety  of  the  anesthetic. 
To  obtain  the  benefit  of  the  warm  vapor  without  the  disad- 

FiG.  7. — Towel  cone. 

vantages  of  the  closed  inhalers,  the  vapor  method  of  etherization  is 
preferred  by  some.  It  is  an  excellent  method  of  anesthesia  to  use  in 
operations  about  the  mouth,  as  the  vapor  can  be  delivered  through  a 
small  tube  passed  into  the  mouth  without  interfering  with  the  opera- 
tion.    There  are  a  number  of  inhalers  for  this  purpose,  of  which 

Fig.  8. — The  Clover  ether  inhaler. 

Gwathmey's  apparatus  is  a  type.  Gwathmey's  vapor  apparatus 
(Fig.  10),  as  described  by  him  {Journal  of  American  Medical  Associa- 
tion, October  27,  1906),  consists  of  two  six-ounce  (180  c.c.)  bottles,  one 
for  chloroform  and  one  for  ether.  Both  bottles  are  placed  in  a  tin 
vessel  containing  thermolite.     This  ''  thermolite  warmer,"  if  placed  in 



boiling  water  for  three  minutes,  will  remain  warm  for  over  one  and  a 
half  hours.  If  the  heat  is  to  be  continued,  this  can  be  accompHshed 
by  simply  taking  the  stoppers  out,  thus  exposing  the  thermolite  to  the 
atmosphere.  The  liquid  then  begins  to  recrystallize,  and  on  turning 
to  a  sohd  form  gives  off  heat  for  another  hour  and  a  half.     In  each  of 

Fig.  9.— The  Bennet  ether  inhaler. 

the  bottles  there  are  three  tubes,  varying  in  length  from  one  that 
reaches  to  the  bottom  of  the  bottle  to  one  that  penetrates  only  the 
stopper,  and  representing  three  degrees  of  vapor  strength.  The  small 
switches  at  the  top  of  each  bottle  are  so  arranged  that  chloroform 
or  ether  can  be  given,  combined  or  separately,  and  in  any  strength 

Fig.   10. — Gwathmey's  vapor  apparatus. 

desired.  In  addition,  by  simply  turning  a  small  lever,  without 
removing  the  mask,  the  patient  receives  pure  air  or  a  mixture  of  oxy- 
gen and  air.  By  compressing  the  hand  bulb,  air  or  oxygen  is  forced 
into  the  apparatus  and  the  warmed  ether  or  chloroform  vapor  is 
carried  to  the  patient  by  the  efferent  tube. 

Inhalers,    whatever    the    variety,    should    always   be    sterilized 



after  use.  Disregard  of  this  precaution  has  been  the  cause  of 
many  of  the  cases  of  postoperative  pneumonia.  Metal  portions  of 
the  inhaler  should  be  boiled  and  the  rubber  parts  soaked  in  a  i  to  20 
solution  of  carboUc  acid  after  each  administration.  The  parts  are 
then  dried,  and  fresh  gauze  packing  is  suppHed  for  the  closed  inhalers 
and  the  open  ones  are  covered  with  new  gauze  or  canton  flannel. 

Administration. — Drop  Method. — The  usual  precautions  ahead}- 
detailed  having  been  observed,  and  the  eyes  of  the  patient  being 
protected  by  a  folded  piece  of  gauze,  the  mask  is  placed  over  the 
mouth  wiih.  the  request  that  the  patient  breathe  naturally  and  regu- 

FlG.   II. — Showing  the  administration  of  ether  by  the  drop  method. 

larly.  As  soon  as  several  breaths  have  been  taken,  a  few  drops  of 
ether  are  poured  upon  the  mask.  After  a  few  more  breaths,  more 
ether  is  added,  gradually  increasing  the  amount  each  time.  If  the 
patient  struggles  or  begins  to  cough  and  choke,  the  amount  of  ether 
should  be  lessened  for  the  time  being.  In  from  five  to  six  minutes  the 
stage  of  excitement  and  struggb'ng  begins,  and  the  ether  should  then 
be  dropped  more  rapidly.  Large  amounts  should  never  be  poured 
on  suddenly,  however,  as  this  simply  irritates  the  respiratory 
tract  and  produces  laryngeal  spasm,  causing  the  patient  to  cough, 
choke,  or  hold  his  breath.  If  the  dropping  is  properly  performed, 
full  anesthesia  should  be  obtained  in  from  ten  to  fifteen  mintues.  By 
the  drop  method  an  even  anesthesia  without  cyanosis  is  produced. 


As  soon  as  the  patient  is  thoroughly  anesthetized,  just  sufficient  ether 
should  be  given  to  keep  him  thoroughly  under  its  effects. 

During  the  anesthesia  the  breathing  should  be  carefully  watched, 
together  with  the  pulse  and  the  eye  reflexes.  Under  the  stimulation 
of  the  ether,  the  respirations  are  increased  in  frequency  and  depth, 
and  are  rather  noisy  in  character  on  account  of  the  increased  amount 
of  mucus  and  saliva  that  collects  in  the  throat.  Irregular  rapid 
respiration  approaching  a  gasping  type  is  unsafe.  The  breathing 
should  not  be  allowed  to  become  gurgling  or  obstructed.  To  prevent 
this,  the  jaw  should  be  held  well  forward  by  placing  the  fingers  back 
of  the  angle,  as  shown  in  the  accompanying  illustration  (Fig.  12). 
This  prevents  the  relaxed  epiglottis  from  being  forced  back  by  the 
tongue  over  the  opening  in  the  larynx,  since,  if  the  jaw  is  pushed  for- 
v/ard,  the  tongue  goes  with  it,  giving  a  clear  passage.     In  holding  the 

Fig.   12. — Proper  method  of  holding  the  jaw  forward. 

jaw  forward,  care  should  be  taken  not  to  use  force  or  bruise  the 
tissues.  If  this  maneuver  does  not  overcome  the  obstruction  from 
the  tongue,  the  latter  should  be  pulled  out  and  held  well  forward  by 
means  of  a  tongue  forceps  or  a  silk  thread  passed  through  its  tip. 
This,  however,  is  seldom  necessary  if  the  jaw  is  properly  held  and  the 
head  is  turned  to  one  side  so  as  to  ailow  the  mucus  and  saliva  to  flow 
out  through  the  corner  of  the  mouth.  Should  vomiting  occur,  the 
inhaler  must  be  removed  and  the  patient's  head  turned  to  one  side  so 
that  the  vomited  matter  can  escape;  and,  before  the  mask  is  reap- 
pHed,  the  mouth  should  be  well  cleared  of  vomitus. 

The  pulse  under  the  effect  of  ether  becomes  somewhat  rapid,  but 
of  greater  volume  and  increased  tension.  At  first  the  pupils  are 
widely  dilated  and  then  tend  to  moderately  contract.  Should  they 
suddenly  dilate  and  remain  so  without  responding  to  hght  in  the 
absence  of  the  conjunctival  reflex,  it  is  a  sign  of  overnarcosis.  Other 
danger  signs  are  a  weak,  thready,  or  irregular  pulse,  and  marked  pallor 


or  cyanosis.  Hiccough  usually  means  that  the  patient  is  getting 
ready  to  vomit.  Rolling  of  the  eyes  and  repeated  acts  of  swallowing 
are  preliminaries  to  the  patient  coming  out.  Both  conditions  require 
more  ether. 

As  the  operation  progresses,  smaller  quantities  of  ether  should  be 
used,  and  the  anesthesia  should  be  so  regulated  that  the  patient  will 
be  just  coming  out  by  the  time  that  he  is  ready  to  be  moved  from  the 
table.  The  amount  of  ether  used  will  depend  upon  the  skill  of  the 
anesthetist  and  the  form  of  inhaler.  With  the  open  inhaler,  from 
two  to  four  ounces  (60  to  120  c.c.)  should  suffice  for  an  hour;  in 
the  closed  inhalers,  much  less  will  be  consumed.  It  should  always 
be  the  aim  of  the  anesthetist  to  use  just  as  little  as  may  be  necessary 
to  keep  the  patient  under  control. 

Semiopen  Method. — Etherization  with  a  semiopen  inhaler  differs 
in  no  material  way  from  the  drop  method.  The  anesthesia  should  be 
started  slowly  by  pouring  into  the  top  of  the  cone  small  quantities 
of  ether  at  a  time.  After  complete  anesthesia  is  obtained,  it  may  be 
maintained  by  the  use  of  less  ether  than  with  the  drop  method,  as  the 
ether  does  not  volatilize  so  rapidly. 

Closed  Method. — The  gauze  in  the  ether  chamber  is  well  saturated 
with  ether  before  commencing  the  anesthesia.  The  cone  is  then 
apphed  and  the  patient  is  instructed  to  take  regular  breaths,  breath- 
ing back  and  forth  through  the  bag.  As  soon  as  he  becomes  accus- 
tomed to  the  apparatus,  ether  is  slowly  turned  on  during  an  inspira- 
tion by  gradually  revolving  the  drum  of  the  ether  chamber  (Fig.  13). 
If  cough  or  signs  of  irritation  occur,  the  amount  of  ether  should  be 
cut  down.  Care  should  always  be  taken  not  to  push  the  anesthetic  too 
fast.  As  the  patient  breathes  into  and  out  of  the  rubber  bag,  it 
should  be  seen  that  the  latter  is  kept  about  two-thirds  full  of  air — it 
should  never  be  allowed  to  become  empty.  Usually  with  a  closed 
inhaler  anesthesia  can  be  produced  in  from  four  to  six  minutes.  On 
account  of  rebreathing  the  same  air,  some  duskiness  of  countenance  is 
to  be  expected,  but  this  may  be  regulated  by  admitting  more  air  or  by 
administering  oxygen.  A  distinct  livid  color  should  not  be  allowed  to 
persist  with  either  a  closed  or  an  open  inhaler.  Such  a  condition  is  a 
sign  of  poor  administration  of  the  anesthetic,  or  else  the  particular 
anesthetic  used  is  not  suited  to  the  case. 

Anesthesia  by  the  closed  method,  besides  being  more  rapid, 
reduces  considerably  the  amount  of  ether  used.  Recovery  from  the 
effects  of  the  anesthesia  is  more  prompt,  and  the  after-effects,  as 
nausea  and  vomiting,   are  greatly   diminished.     Furthermore,   the 



ether  vapor  inhaled  from  the  bag,  being  warm,  is  safer,  more  effective, 
and  less  apt  to  produce  irritation  of  the  respiratory  tract. 

Vapor  Method. — It  is  preferable  to  start  the  anesthesia  by  some 
of  the  quick  methods,  as  nitrous  oxid  gas  followed  by  ether,  or  by 
ethyl  chlorid  followed  by  ether,  and,  when  the  patient  is  well  under 
its  influence,  the  ether  vapor  is  substituted.  The  vapor  method  may, 
however,  be  used  from  the  beginning,  if  desired,  starting  with  a  me- 
dium percentage  of  vapor,  and  then  working  to  the  highest.     When 

Fig.   13. — Showing  the  administration  of  ether  with  a  closed  inhaler. 

completely  under,  a  medium  or  low  percentage  of  vapor  is  used, 
according  to  the  depth  of  anesthesia  desired.  The  mask  used  in  this 
method  is  covered  with  gauze,  over  which  an  impermeable  material, 
as  rubber  tissue  or  oil  silk  is  placed,  with  a  small  opening  in  the  center 
about  the  size  of  a  ten-cent  piece,  through  which  additional  anesthetic 
may  be  dropped  if  it  is  found  to  be  difficult  to  induce  narcosis  with 
the  vapor  alone. 

The  vapor  method  gives  a  light  anesthesia,  just  abolishing  the 
reflexes.  The  breathing  more  nearly  approaches  the  normal,  with- 
out the  snoring  rapid  respiration  usual  to  ether.  The  pulse  is 
nearer  normal,  and  the  duskiness  of  countenance  often  present 
with  the  closed  method  is  absent. 


Chloroform  is  a  clear,  colorless,  heavy,  volatile  liquid  with  a  sweet- 
ish taste  and  characteristic  odor.     When  used  for  anesthetic  purposes. 


it  should  be  absolutely  pure  and  neutral  to  litmus.  Under  the  influ- 
ence of  heat  or  light,  it  decomposes  into  hydrochloric  acid,  chlorin, 
etc.,  hence  it  should  always  be  kept  in  well-stoppered,  dark  amber- 
colored  bottles  and  in  a  cool  place.  It  is  more  irritating  to  the  skin 
than  ether  and,  if  confined,  will  produce  bhsters.  For  this  reason  the 
lips,  nose,  and  cheeks  with  which  it  may  come  in  contact  during 
anesthesia  should  be  well  protected  with  vaselin. 

When  inhaled,  chloroform  vapor  has  a  depressant  effect  upon  all 
the  vital  functions,  but  especially  upon  the  circulation, lowering 
blood-pressure  to  a  marked  degree  through  vasomotor  depression. 
It  is  less  of  an  irritant  to  the  respiratory  tract  and  more  agreeable  to 
take  than  ether,  hence  the  primary  stage  of  excitement  is  milder. 
Upon  the  kidneys,  it  is  likewise  less  irritating.  It  causes  slight  tem- 
porary fatty  changes  in  the  kidneys,  heart  muscle,  and  liver  (more 
marked  upon  the  latter)  which  may  be  severe  and  later  lead  to  fatal 
results  if  these  organs  are  already  diseased. 

Death  from  chloroform  is  usually  sudden  and  without  premoni- 
tory signs.  Vasomotor  paralysis  causing  dilatation  of  the  vessels 
and  capillaries  and  fatal  syncope  is  the  primary  cause,  though  the 
inhiditory  action  of  the  drug  upon  the  heart  itself  may  contribute. 
Respiratory  failure  is  not  common  as  a  primary  complication,  but  is 
secondary  to  the  failure  of  the  vasomotor  centers.  Many  of  the 
deaths  from  chloroform  occur  early  in  its  administration  when,  during 
the  stage  of  excitement  and  struggling,  more  of  the  drug  is  inhaled 
than  is  expected,  or  it  is  pushed  too  rapidly  in  an  attempt  to  overcome 
the  struggHng.  With  a  trained  and  watchful  assistant  as  an  anes- 
thetist, chloroform  is  robbed  of  many  of  its  dangers,  but  in  inex- 
perienced hands  it  is  a  most  dangerous  drug,  being  estimated  to  be 
about  five  times  more  fatal  than  ether. 

Chloroform  is  the  strongest  anesthetic  we  possess,  and  should 
always  be  administered  well  diluted  with  air.  A  stronger  vapor  than 
2  per  cent,  is  a  dangerous  dose.  In  this  respect  it  differs  from  nitrous 
oxid  and  ether,  in  the  use  of  which  a  well-saturated  vapor  is  required. 
A  mixture  of  chloroform  and  oxygen  is  safer  than  chloroform  and  air. 
The  use  of  this  combination  is  less  often  accompanied  by  circulatory 
depression,  while  cyanosis  and  postoperative  vomiting  are  less  fre- 

Chloroform  should  always  be  administered  warm.  This  can  be 
accompUshed  by  using  some  one  of  the  warm  vapor  inhalers,  or  by 
simply  placing  the  bottle  containing  the  drug  in  warm  water  (ioo° 
F.,  38°  C.)  every  few  moments. 


Chloroform  should  not  be  given  with  the  head  very  high,  or  with 
the  patient  sitting  up,  on  account  of  the  danger  of  syncope;  this 
precaution  should  also  be  borne  in  mind  when  lifting  or  moving  per- 
sons under  the  influence  of  chloroform.  As  a  rule,  the  recovery  from 
chloroform  anesthesia  is  quicker  than  from  ether,  though  the  vomit- 
ing may  last  longer. 

Suitable  Cases. — Chloroform  is  generally  preferred  to  ether  in 
young  children  and  in  those  over  sixty  years  of  age  who  are  free  from 
myocardial  disease,  for  the  reason  that  it  causes  less  irritation  of 
the  respiratory  tract.  It  is  preferred  to  ether  for  patients  with 
advanced  Bright' s  disease  who  are  free  from  myocardial  trouble,  in 
obstructive  conditions  of  the  larynx  or  trachea,  and  for  those  whose 
lungs  are  involved  by  such  conditions  as  tuberculosis,  asthma, 
bronchitis,  etc. 

In  heart  disease  with  broken  compensation  and  dyspnea,  in 
aneurysm,  and  in  cases  of  marked  degeneration  of  the  blood- 
vessels, chloroform  is  better  than  ether  on  account  of  the  milder 
preliminary  stages.  In  cases  of  myocarditis  and  of  fatty  degeneration 
it  is  dangerous  and  some  other  drug  should  be  employed. 

In  parturition  it  is  safer  than  in  health,  because  only  a  partial 
action  is  required,  and  fright  and  apprehension  which  may  be  the 
cause  of  some  of  the  fatalities  are  absent.  When,  however,  deep 
surgical  anesthesia  is  required  in  such  cases,  ether  is  indicated. 
In  eclampsia  chloroform  should  not  be  used  on  account  of  its  destruc- 
tive action  upon  the  liver.  In  fact,  in  the  presence  of  any  liver  lesion 
it  should  be  avoided. 

Chloroform  should  be  avoided  as  an  anesthetic  in  hemorrhage  or 
shock,  on  account  of  its  depressant  effect  upon  the  circulation;  and 
likewise  in  anemia,  as  it  decreases  hemoglobin.  In  cerebral  surgery, 
chloroform  is  preferred  by  many  surgeons,  and  also  in  operations 
about  the  face  and  mouth,  as  it  causes  but  little  cough  and  flow  of 
saliva,  and  the  anesthesia  can  be  maintained  with  but  a  small 
amount  of  anesthetic.  As  its  vapor  is  not  inflammable,  it  can  be 
employed  in  operations  about  the  mouth  or  face  while  the  cautery 
is  being  used.  In  minor  surgical  cases,  where  the  operation  is 
often  performed  under  incomplete  anesthesia,  chloroform  is  con- 
traindicated.  In  ophthalmic  operations,  where  the  condition  of 
the  pupil  cannot  be  ascertained,  ether  is  preferred  to  chloroform. 

Apparatus. — Chloroform  should  never  be  administered  in  a  closed 
inhaler.  Either  the  open  drop  method,  with  a  free  mixture  of  air,  or 
the  warm  vapor  method  should  be  employed.     For  the  former,  a 



handkerchief,  the  corner  of  a  towel  (Fig.  14),  or  a  piece  of  gauze  will 
suffice,  but  a  mask,  such  as  Skinner's,  Esmarch's  (see  Fig.  3),  or 
Schimmelbusch's  (see  Fig.  4),  covered  with  canton  flannel  or  several 
layers  of  gauze,  is  more  suitable.  In  addition,  a  drop  bottle  (see 
Fig.  5)  from  which  the  flow  can  be  accurately  regulated,  and  a  recep- 
tacle for  warm  water  will  be  required. 

Fig.   14. — Chloroform  mask  improvised  from  the  corner  of  a  towel. 

Different  forms  of  apparatus  for  accurately  estimating  the 
strength  of  vapor,  as  Junker's  (Fig.  15),  Braun's,  Gwathmey's  (see 
Fig.  10),  etc.,  are  often  used.  These  are  supplied  with  a  tracheal 
tube  and  are  especially  useful  in  operations  about  the  mouth  or  throat. 
By  squeezing  the  bulb,  air  is  forced  through  the  warmed  chloroform, 
and  a  vapor  containing  a  definite  mixture  of  chloroform  and  air  is 
administered.     By  attaching  the  bulb  to  a  tube  connected  with  an 

Fig.   15. — Junker's  chloroform  inhaler. 

oxygen  cylinder,  oxygen  may  be  readily  administered  instead  of  air. 

The  same  care  as  to  the  cleanhness  of  the  chloroform  mask  should 
be  observed  as  would  be  with  ether  inhalers.  After  each  anesthesia 
the  metal  framework  should  be  boiled  and  then  recovered. 

Administration. — The  patient's  lips,  nose,  mouth,  and  cheeks 
should  be  well  greased  with  vaselin  or  lanolin.  The  anesthetic  is 
started  by  holding  the  mask  wet  with  a  few  drops  of  warm  chloro- 



form  4  or  5  inches  (lo  to  12  cm.)  from  the  face  (Fig.  16),  the  patient 
being  told  to  breathe  naturally  and  regularly.  As  soon  as  the  patient 
grows  accustomed  to  the  vapor,  the  chloroform  is  dropped  steadily  at 
a  rate  of  10  to  30  drops  a  minute,  and  the  mask  is  brought  nearer  the 
face,  being  careful,  ho^Yever,  not  to  touch  the  skin  with  portions  of 
the  mask  wet  with  chloroform  (Fig.  17).  When  given  gradually  in 
this  way,  the  struggHng  is  not  usually  prolonged  or  violent.  The 
anesthetic  should  never  be  poured  on  suddenly  in  large  quantities; 
it  must  always  be  administered  well  diluted  with  air.  In  the  stage  of 
excitement,  chloroform  must  he  given  with  extreme  care;  if  the  patient 

Fig.   16. — Showing  the  method  of  administering  chloroform  (first  step). 

struggles,  the  drug  should  not  be  pushed,  otherwise,  when  the  patient 
holds  his  breath,  as  he  will  in  such  cases,  a  large  quantity  of  the  anes- 
thetic is  retained  in  the  lungs,  and,  when  he  takes  a  deep  breath,  a 
dangerous  amount  may  be  inhaled  from  the  aheady  oversaturated 
mask.  Coughing  and  vomiting  mean  that  the  vapor  is  too  strong, 
and  it  should  be  promptly  diluted  as  it  should  also  if  the  patient's 
breathing  becomes  embarrassed.  The  jaw  must  be  kept  well  forward 
if  there  is  the  slightest  impediment  from  the  tongue  to  free  respiration. 
When  the  patient  is  fully  anesthetized,  only  smaU  quantities  of  the 
anesthetic  should  be  administered,  just  sufficient  to  keep  him  under. 
With  chloroform  anesthesia,  we  have  practically  the  same  stages 



as  with  ether.  l)ut  the)-  succeed  each  other  more  rapidly,  and  a  dan- 
gerous degree  of  anesthesia  is  quickly  produced  unless  proper 
care  be  taken.  The  stage  of  excitement  is  less  marked  and  shorter 
than  with  ether,  and  the  patient  presents  a  more  tranquil  appearance 
in  every  way.  It  should  be  the  aim  of  the  anesthetist  to  keep  the 
patient  in  about  the  following  condition:  regular  and  fairly  deep 
respirations,  with  only  a  slight  snore;  pupils  moderately  contracted 
and  sluggishly  sensitive  to  hght;  conjunctival  reflex  just  aboHshed; 
full  muscular  relaxation;  and  a  good  color  without  blueness  of  the 
lips  or  cheeks.     The  latter  is  an  indication  for  a  weaker  vapor  and 

Fig.   17. — Showing  the  method  of  administering  chloroform  (second  step). 

more  air  or  oxygen.  With  the  ordinary  chloroform  mask,  oxygen 
may  be  administered  by  simply  inserting  the  tube  leading  from  the 
oxygen  cylinder  under  the  edge  of  the  mask. 

During  the  entire  anesthesia,  careful  and  close  watch  should  be 
kept  over  the  respirations,  the  pulse,  the  condition  of  the  eye  reflexes, 
and  the  general  appearance  of  the  patient.  It  is  only  by  the  constant 
and  undivided  attention  of  the  anesthetist  that  the  safety  of  the 
patient  can  be  guaranteed.  The  slightest  alteration  in  the  respira- 
tions should  be  taken  as  a  warning,  as  this  is  often  the  precursor  to 
circulatory  failure.  Very  shallow,  irregular,  or  gasping  respiration,  a 
weak,  thready,  or  intermittent  pulse,  sudden  and  continued  dilatation 


of  the  pupils  In  the  absence  of  eye  reflexes,  and  marked  duskiness  or 
sudden  pallor  of  the  skin,  are  all  indications  that  a  dangerous  stage 
of  narcosis  has  been  reached. 

The  administration  of  anesthetics  by  the  vapor  method  has 
already  been  described  under  ether  anesthesia  (page  17),  and  will  not 
be  repeated  here.  With  chloroform,  it  is  an  especially  valuable 
method  to  employ,  as  the  warm  vapor  may  be  administered  in  a  defi- 
nite strength,  and  with  air  or  oxygen  as  desired. 


Nitrous  oxid  is  a  colorless  gas,  heavier  than  air,  and  with  no  per- 
ceptible odor  or  taste.  It  is  obtained  in  a  liquid  form,  highly  com- 
pressed in  steel  cyUnders  or  containers,  from  which,  when  liberated, 
it  escapes  as  a  gas.  It  has  marked  anesthetic  properties,  though  the 
anesthesia  is  not  so  profound  as  that  from  ether  or  chloroform.  It 
increases  the  rate  and  depth  of  respiration  and  accelerates  the  heart 
action,  at  the  same  time  raising  blood-pressure.  If  pushed  too  far, 
the  respirations  cease,  though  the  heart  continues  to  beat  for  some 
time.  For  short  operations  it  is  the  safest  of  all  the  general  anes- 
thetics, I  in  100,000  being  the  generally  accepted  death  rate. 

Anesthesia  from  nitrous  oxid  cannot  be  maintained  for  more 
than  fifty  or  sixty  seconds  without  air,  on  account  of  the  develop- 
ment of  symptoms  of  asphyxiation.  Used  with  the  proper  admix- 
ture of  air  or  oxygen,  however,  an  anesthesia  for  an  hour  or  more 
may  be  safely  maintained.  According  to  Hewitt,  mixtures  con- 
taining 5  to  7  per  cent,  of  oxygen  are  best  suited  for  adult  males,  and 
mixtures  of  7  to  9  per  cent,  of  oxygen  are  best  for  females  and  chil- 
dren. Mixtures  of  nitrous  oxid  and  air,  composed  of  from  14  to  18 
per  cent,  of  the  latter  for  men,  and  from  18  to  22  per  cent,  for  women, 
give  the  next  best  results. 

Nitrous  oxid  is  very  rapid  in  its  action,  producing  complete 
unconsciousness  in  from  one  to  two  minutes,  and  is  the  most  agree- 
able of  the  general  anesthetics  to  take.  The  patient  comes  out  of  it 
very  quickly,  usually  in  from  thirty  to  sixty  seconds,  and  its  use  is 
not  followed  by  nausea  and  vomiting.  The  lung,  kidney,  and  heart 
complications  of  ether  and  chloroform  are  likewise  absent. 

Suitable  Cases. — When  used  pure,  nitrous  oxid  is  suitable  only 
for  short  procedures  lasting  about  a  minute,  such  as  extracting  teeth 
and  making  incisions  for  drainage,  etc. 

With  the  admixture  of  air  or  oxygen  in  proper  quantities  to  pre- 
vent asphyxial  symptoms,  and  administered  by  an  expert,  it  may  be 


made  applicable  for  anesthesia  in  some  major  surgical  operations 
not  consuming  a  great  deal  of  time,  as  well  as  in  many  of  the  minor 
ones.  It  is  an  excellent  anesthetic  to  employ  for  the  reduction  of 
fractures  requiring  only  a  moderate  amount  of  muscular  relaxation, 
and  for  breaking  up  adhesions  in  ankylosed  joints.  When  local  anes- 
thesia is  contraindicated,  it  becomes  the  anesthetic  of  choice  for 
abscess,  felon,  empyema,  benign  tumors,  strangulated  hernia,  varico- 
cele, minor  amputations,  exploratory  operations,  etc.  Within  the  last 
few  years  the  scope  of  nitrous  oxid  and  oxygen  anesthesia  has  been 
greatly  enlarged,  some  operators  employing  it  in  their  work  to  the 
exclusion  of  ether  in  operations  of  considerable  magnitude  upon 
the  biliary  passages,  kidney,  bladder,  intestines,  and  stomach.  It 
should  be  remembered,  however,  in  connection  with  some  of  the  above 
abdominal  cases,  that  often  complete  relaxation  is  not  obtained  under 
this  form  of  anesthesia. 

Nitrous  oxid  is  contraindicated  in  cases  of  dilated  heart  or  advanced 
valvular  disease,  and  in  patients  with  atheroma  of  the  blood-vessels, 
on  account  of  the  danger  of  cerebral  hemorrhage.  In  children,  the 
mask  and  formidable  appearing  apparatus  frequently  cause  so  much 
fear  as  to  preclude  its  use.  It  is  not  a  suitable  anesthetic  to  employ 
in  patients  with  narrow  or  abnormal  air  passages,  or  in  those  suffering 
from  goiter,  enlarged  tonsils,  or  adenoids.  In  operations  about  the 
rectum  and  perineum,  it  is  sometimes  unsatisfactory,  as  the  patient 
may  stiffen  up  or  straighten  out  the  limbs,  thus  interfering  with  the 
operator.  The  same  may  be  said  of  its  use  in  alcoholics,  or  strong, 
robust,  or  fat  individuals,  though,  according  to  Gwathmey,  by  pre- 
liminary medication  with  morphin  alone,  or  with  morphin  and  chlo- 
retone,  or  morphin  and  hyoscin,  any  patient  can  be  anesthetized 

Apparatus. — Nitrous  oxid  may  be  administered  alone  or  with  air 
by  means  of  any  of  the  usual  inhalers  for  that  purpose,  such  as  Hew- 
itt's, Gwathmey's,  Bennett's  (Fig.  i8),  etc.  In  general,  these  consist 
of  a  metal  mask  with  a  pneumatic  rubber  rim  that  fits  the  face 
accurately  so  as  to  exclude  air,  a  gas  chamber  with  inspiratory  and 
expiratory  valves  or  openings,  and,  attached  to  the  gas  chamber, 
a  rubber  balloon  connected  by  rubber  tubing  with  the  nitrous  oxid 
cylinder.  With  such  apparatus,  air  may  be  admitted  through  the 
openings  provided  for  that  purpose  or  the  inhaler  may  be  removed 
every  two  to  five  inspirations,  allowing  the  patient  to  get  a  supply  of 
pure  air.  Oxygen  may  likewise  be  administered  by  passing  the 
oxygen  tube  under  the  rim  of  the  mask. 



When  a  definite  amount  of  oxygen  is  to  be  given,  a  special  appara- 
tus, as  that  of  Hewitt  (Fig.  19),  Gwathmey  (Fig.  20),  Teter,  Cunning- 
ham, or  Gatch,  is  essential.  With  these  inhalers  any  desu"ed  com- 
bination of  nitrous  oxid  gas  and  oxygen  may  be  obtained  by  regulating 
special  s^^'itches,  which  are  provided  with  indicators  showing  the 

Fig,   18. — The  Bennett  nitrous  oxid  gas  inhaler. 

Fig.   19. — The  Hewitt  nitrous  oxid  gas  and  oxygen  inhaler. 

exact  strength  of  the  vapor  which  the  patient  receives.  Carbon 
dioxid,  which  has  been  proved  so  valuable  as  a  respiratory  stimulant, 
is  provided  by  rebreathing  or  by  connecting  the  apparatus  with  a 
tank  of  CO9. 



As  with  all  inhalers,  the  metal  parts  should  be  boiled  and  the  rub- 
bers sterilized  in  a  solution  of  i  to  20  carboKc  acid  after  use.  Before 
using,  the  apparatus  should  always  be  tested  to  see  that  it  works 

Administration. — In  giving  pure  nitrous  oxid,  the  apparatus  is 
properly  connected  with  the  supply  cylinder,  and  the  rubber  balloon 
is  about  three-fourths  filled  with  gas.  The  gas  should  be  turned  on 
slowly,  as,  at  times,  when  suddenly  released,  it  escapes  from  the  cylin- 
der with  a  loud  noise  which  might  tend  to  frighten  a  nervous  patient. 
The  face-piece  is  then  tightly  appUed  over  the  mouth  and  nose,  so 
that  air  cannot  be  drawn  in  around  the  rubber  rim.     The  expiratory 

Fig.  20. — Gwathmey's  nitrous  oxid  gas  and  oxygen  inhaler. 

valve  is  opened  and  the  patient  is  told  to  breathe  regularly.  After 
two  or  three  breaths  of  air,  during  which  the  patient  becomes  accus- 
tomed to  the  apparatus,  the  gas  is  allowed  to  enter  the  mask  by  open- 
ing the  proper  stopcock.  The  patient  thus  breathes  in  pure  nitrous 
oxid  and  expires  nitrous  oxid  and  air,  so  that  he  constantly  receives 
more  nitrous  oxid  into  the  lungs.  After  a  few  breaths,  the  expiratory 
valve  is  closed  and  the  patient  breathes  the  gas  back  and  forth. 

The  first  few  inspirations  of  pure  gas  are  soon  followed  by  a  change 
in  the  color  of  the  face — it  becomes  dusky,  and  finally  a  deep  Uvid 
hue.     There  is  at  first  incoherent  speech,  but  this  is  soon  followed  by 



the  anesthetic  snoring,  rapid  respiration,  and  a  laryngeal  stertor. 
There  is  usually  tremor  or  twitching  of  the  superficial  muscles  of  the 
eyes,  mouth,  neck,  etc.,  and  at  times  complete  rigidity  and  violent 
jactitations  of  the  limbs.  The  anesthetic  cannot  be  continued 
beyond  this  point  without  danger  of  asphyxiation.  If  the  mask  is 
removed,  there  is  still  a  period  of  surgical  anesthesia,  lasting  about  a 
minute.  This  is  soon  followed  by  a  reactionary  redness  or  blush 
about  the  face,  and  a  return  to  normal  breathing.  By  reapplying  the 
mask  before  the  patient  comes  entirely  out,  and  administering  more 
nitrous  oxid,  the  anesthesia  may  be  prolonged  nearly  an  hour,  pro- 

FiG.  21. — Showing  the  method  of  administering  nitrous  oxid  gas. 

vided  sufficient  air  is  admitted  to  avoid  extreme  cyanosis,  stertor, 
and  muscular  twitchings,  and  yet  not  so  much  as  to  keep  the  patient 
insufficiently  anesthetized.  This  may  be  accomplished  by  allowing 
two  to  five  breaths  of  nitrous  oxid  to  one  of  air,  or  the  air  may  be 
administered  in  combination  with  the  nitrous  oxid  through  the  open- 
ing provided  on  the  inhaler  for  that  purpose.  A  slight  duskiness  of 
the  countenance,  moderate  snoring,  and  regular  respiration  should  be 
aimed  at. 

Administered  with  oxygen,  a  complete  absence  of  symptoms  of 
asphyxia  is  secured.  An  even  anesthesia  is  best  obtained  with  some 
form  of  apparatus  that  accurately  regulates  the  percentage  of  oxygen. 
The  technic  is  essentially  the  same  as  that  employed  in  giving  pure 


nitrous  oxid.  The  patient  first  breathes  pure  air,  then  the  nitrous  oxid 
is  turned  on,  and  finally  the  oxygen.  Starting  with  but  a  very  small 
proportion  of  oxygen  (2  to  3  per  cent.)  it  may  be  increased  to  from  5 
to  10  per  cent.,  or  more,  depending  upon  the  case.  Enough  oxygen 
should  always  be  given  to  prevent  cyanosis  without  detracting  from 
the  anesthetic  effects  of  the  nitrous  oxid.  There  is  no  doubt  that  it 
requires  special  training  for  one  to  become  expert  in  administering 
this  combination.  Success  depends  upon  the  abihty  of  the  anesthe- 
tist to  provide  a  combination  of  gas  and  oxygen  that  will  produce 
narcosis  without  cyanosis.  With  the  proper  amount  of  oxygen,  the 
patient  goes  under  the  anesthetic  in  two  to  three  minutes  without 
any  of  those  unpleasant  symptoms  seen  with  pure  nitrous  oxid,  the 
color  of  the  skin  is  normal,  the  breathing  becomes  regular  and  slightly 
snoring,  and  the  pulse  may  be  slightly  increased  in  rate.  Recovery  is 
rapid  and  is  usually  unaccompanied  by  any  unpleasant  after-effects. 


By  this  method  the  patient  is  thoroughly  anesthetized  with  gas 
and  then  a  change  is  slowly  made  to  ether.  It  is  a  most  valuable 
method  for  avoiding  the  disagreeable  effects  of  the  early  stages  of 
anesthesia  ordinarily  encountered  when  straight  ether  is  admin- 
istered from  the  start.  A  combination  of  gas  and  ether  carries  the 
patient  into  a  stage  of  surgical  anesthesia  very  rapidly — usually  in 
about  one  to  three  minutes.  Much  less  ether  is  required  both  in 
starting  and  maintaining  narcosis  than  when  ether  alone  is  employed, 
and,  the  patient  not  being  saturated  with  the  drug,  the  after-effects 
of  ether  anesthesia  are  not  nearly  so  frequent  or  pronounced.  It  is 
safer  than  ether  given  alone  by  the  open  or  semiopen  inhalers,  prob- 
ably because  the  stage  of  excitement  is  absent,  and,  in  the  second 
place,  the  carbon  dioxid  content  is  maintained  and  the  ether  vapor 
is  warmed  through  the  constant  rebreathing;  and,  finally,  a  much 
smaller  amount  of  the  anesthetic  is  required. 

Apparatus. — If  desired,  the  gas  may  be  administered  by  any  of  the 
ordinary  nitrous  oxid  gas  inhalers,  and  the  ether  by  the  open  or  semi- 
open  method,  though  a  combination  gas  and  ether  apparatus,  such  as 
Clover's,  Hewitt's,  Bennett's  (Fig.  22),  Gwathmey's  (Fig.  23),  or 
Pedersen's,  is  preferable  and  more  convenient.  These  inhalers  con- 
sist of  the  usual  metal  mouth-piece  and  inflatable  rubber  rim,  inspira- 
tory and  expiratory  valves,  and  gas  bag.  In  addition,  the  inhalers 
have  an  ether  chamber  containing  gauze  upon  which  the  ether  is 


poured.  They  are  arranged  so  that  gas  is  first  administered  in  the 
usual  way,  and  then  by  slowly  revolving  a  drum  the  ether  chamber  is 
gradually  opened,  the  quantity  of  gas  at  the  same  time  being  corre- 
spondingly diminished,  until  finally  the  patient  receives  full  strength 

Fig.   22. — The  Bennett  gas  and  ether  apparatus. 

ether  vapor.  In  the  Bennett  apparatus  the  gas  bag  is  removed  as 
soon  as  the  patient  is  well  under  the  nitrous  oxid,  and  a  second  bag  is 
substituted;  with  the  Gwathmey  inhaler,  this  is  improved  upon,  and 

Fig.  23. — Gwathmey's  gas  and  ether  apparatus. 

but  one  bag  is  used  for  both  gas  and  ether.  As  with  all  apparatus 
having  mechanism  likely  to  get  out  of  order,  the  inhalers  should 
always  be  tested  before  using.  The  same  inhaler  should  never  be 
taken  from  one  person  to  another  without  sterilization. 


Administration. — The  apparatus  is  properly  connected  and  the 
gauze  in  the  ether  chamber  is  well  saturated  with  ether.  The  mask  is 
applied  to  the  face  so  that  it  fits  snugly,  and  the  patient  is  instructed 
to  breathe  naturally.  As  soon  as  it  is  seen  that  the  patient  is  breath- 
ing properly,  the  expiratory  valve  is  opened  and  the  nitrous  oxid  is 
turned  on.  After  a  few  breaths  the  expiratory  valve  is  closed  and  the 
patient  breathes  the  gas  back  and  forth,  gradually  going  under  its 
influence,  which  is  denoted  by  duskiness  of  color,  irregular  snoring 
respiration,  and  muscular  twitching. 

The  addition  of  ether  vapor  is  now  commenced  by  rotating  the 
ether  chamber  slowly.  A  small  amount  of  ether  is  administered  at 
first,  and  this  is  gradually  increased  until  the  patient  is  getting  the  full 
strength  of  ether.  During  this  period,  if  symptoms  of  asphyxia 
from  the  gas  appear,  small  quantities  of  air  should  be  admitted  from 
time  to  time  through  the  air  valve,  but  not  in  such  amount  as  to  allow 
the  patient  to  come  out.  As  soon  as  anesthesia  is  well  established, 
which  usually  takes  less  than  two  minutes,  the  gas  is  discontinued  and 
the  administration  of  the  ether  is  proceeded  with  in  the  usual  way 
when  using  a  closed  cone. 

In  giving  a  combination  of  gas  and  ether,  care  must  be  taken  to 
turn  on  the  ether  rather  slowly  at  first.  If  the  patient  commences  to 
cough  and  hold  his  breath,  the  ether  should  be  turned  on  less  rapidly, 
or  entirely  stopped,  until  regular  breathing  is  again  established. 
When  administered  properly,  the  patient  goes  under  the  anesthetic 
with  surprising  quickness,  without  any  discomfort  or  struggling,  and, 
after  anesthesia  is  once  estabhshed,  but  little  anesthetic  is  required 
to  maintain  it.  Some  duskiness  of  countenance  and  cyanosis  are  to 
be  expected  from  the  nitrous  oxid,  and  the  constant  rebreathing  of  the 
same  vapor,  but  this  may  be  controlled  by  a  careful  regulation  of  the 
air  valves. 


Ethyl  chlorid  is  a  colorless,  very  volatile  and  inflammable  liquid. 
If  pure,  it  has  an  ethereal  odor,  and  should  not  be  acid  to  litmus. 
For  general  anesthetic  purposes  the  purest  quality  of  the  drug  should 
be  used,  and  only  that  labelled  "for  general  anesthesia."  This  can  be 
obtained  in  containers  furnished  with  a  spring  stopcock,  which  per- 
mits the  drug  to  be  administered  in  a  fine  stream  in  any  desired  quan- 
tity (Fig.  24),  or  in  hermetically  sealed  glass  tubes  containing  about 
I  1/4  drams  (5  c.c.)  of  the  drug.  The  latter  is  best  suited  for  the 
closed  inhalers,  the  whole  amount  being  emptied  into  the  inhaler  at 



once.     Ethyl  chlorid  Is  decomposed  by  light  and  air,  hence  it  should 
be  kept  in  a  dark  place  and  in  tightly  stoppered  tubes. 

When  inhaled,  it  is  very  rapidly  absorbed  and  is  quickly  eHmi- 
nated,  anesthesia  being  produced  in  from  thirty  seconds  to  a  minute  or 
so,  and  lasting  two  to  three  minutes  after  the  withdrawal  of  the  anes- 
thetic. Recovery  is  not  quite  so  rapid  as  with  nitrous  oxid,  and  after- 
effects, such  as  headache,  nausea,  vomiting,  and  dizziness,  are  not  at 
all  uncommon.  It  is  not  nearly  so  safe  as  nitrous  oxid,  nor  so  pleas- 
ant an  anesthetic  to  take.  It  has  the  advantage,  however,  of  not 
producing  cyanosis,  and  the  anesthetic  effects  are  more  prolonged; 

Fig.  24. — Ethyl  chlorid  tube. 

fiu-thermore,  it  may  be  administered  without  special  apparatus.  It 
stimulates  both  the  heart  and  respiration,  increasing  the  rate  and  the 
depth  of  the  latter,  but  it  lowers  blood-pressure  through  dilatation  of 
the  peripheral  vessels. 

Suitable  Cases. — Ethyl  chlorid  is  employed  mainly  for  brief 
operations  or  for  examinations  not  requiring  full  muscular  relaxation, 
and  as  a  preliminary  to  ether  to  get  the  patient  under  rapidly  without 
strugghng  and  excitement.     It  acts  especially  well  in  children  on 

Fig.  25. — Showing  the  Schimnaelbusch  mask  covered  with  gauze  and  oil  silk  for  the 
administration  of  ethyl  chlorid. 

account  of  its  rapidity  of  action.  It  should  never  be  immedi- 
ately followed  by  chloroform,  as  both  are  circulatory  depressants. 
Its  use  is  contraindicated  when  there  is  any  respiratory  obstruction. 
Apparatus. — Omng  to  its  great  volatility,  ethyl  chlorid  is  most 
satisfactorily  administered  by  means  of  a  closed  inhaler,  though  the 
semiopen  method  may  be  employed,  and  is  preferred  by  many  as 
being  safer.     For  the  latter,  one  may  employ  an  Esmarch  or  Schim- 



melbusch  mask,  over  the  gauze  of  which  is  placed  some  impervious 
material,  as  oil  silk  or  rubber  tissue,  with  a  small  opening  through 
which  the  drug  is  sprayed  (Fig.  25);  or  an  Allis  inhaler  may  be  used, 
leaving  a  small  opening  in  the  top.  Any  of  the  ordinary  closed  inhal- 
ers may  be  utilized  for  administering  ethyl  chlorid  by  simply  spraying 
the  drug  into  the  ether  bag. 

There  are  a  number  of  inhalers,  however,  devised  especially  for 
this  drug  and  similar  anesthetics.  Ware's  inhaler  (Fig.  26)  consists 
of  a  pliable  rubber  mouth-piece,  to  the  top  of  which  is  fitted  a  metal 
chimney.  At  the  point  the  latter  joins  the  mouth-piece,  several 
layers  of  gauze  are  interposed  upon  which  the  anesthetic  is  sprayed 

through  the  top  of  the  apparatus.  The 
somnoform  inhaler  consists  of  a  glass  face- 
piece  with  an  inflatable  rubber  rim  and 
rubber  balloon.  The  balloon  is  attached 
to  the  mouth-piece  by  a  T-shaped  cham- 
ber which  is  provided  with  a  valve  and  a 
small  opening  through  which  the  anes- 
thetic may  be  sprayed. 

Administration. — In  administering 
ethyl  chlorid  by  the  closed  method,  the 
inhaler  is  placed  over  the  patient's  face 
during  expiration  in  order  to  fill  the  bag, 
and,  as  soon  as  the  patient  is  breathing 
regularly,  from  i  to  i  1/4  dr.  (4  to  5  c.c.) 
of  ethyl  chlorid  are  sprayed  into  the  bag, 
or,  if  a  special  inhaler  is  used,  into  the  opening  provided  for  the 
purpose.  If  the  face-piece  be  tightly  applied,  so  as  to  prevent  the 
entrance  of  air,  signs  of  anesthesia  appear  in  from  thirty  seconds  to 
one  minute.  As  soon  as  anesthesia  is  produced,  the  patient  should 
be  allowed  to  have  air. 

Full  anesthesia  is  characterized  by  rapid  and  shghtly  stertorous 
breathing,  dilated  pupils,  absence  of  conjunctival  reflex,  and  more 
or  less  complete  relaxation.  There  is  no  cyanosis,  though  the  color 
of  the  skin  is  heightened  from  the  dilatation  of  the  peripheral  vessels. 
The  inhaler  should  now  be  removed  and  the  operation  proceeded  with, 
or  else  ether  is  substituted.  If  the  patient  recover  too  rapidly,  more 
anesthetic  may  be  given,  provided  a  plentiful  supply  of  air  is  allowed. 
By  an  interrupted  administration  of  ethyl  chlorid — that  is,  first 
securing  deep  narcosis  and  then  giving  air — a  prolonged  light  anes- 
thesia may  be  obtained,  though  at  times  muscular  relaxation  is  not 

Fig.  26. — Ware's  ethyl 
chlorid  inhaler. 


complete  and  the  patient  is  apt  to  remain  partly  conscious.  Danger 
signs  from  ethyl  chlorid  anesthesia  are  gasping,  shallow  respirations, 
pupils  widely  dilated  and  not  reacting  to  light,  and  general  pallor  of 
the  skin. 

Administered  by  the  semiopen  method,  a  greater  quantity  of  the 
drug  will  be  necessary,  and  somewhat  more  time  will  be  consumed  in 
getting  the  patient  under  than  by  the  closed  method.  The  mask  is 
placed  over  the  face,  air  being  excluded  as  far  as  possible  by  surround- 
ing it  with  a  towel,  and  the  drug  is  simply  sprayed  upon  the  inhaler 
in  a  steady  stream  until  anesthesia  is  produced. 


The  addition  of  ether,  alcohol,  and  other  drugs  to  chloroform  has 
been  extensively  practised  for  the  purpose  of  modifying  the  action  and 
avoiding  the  dangers  of  the  latter.  There  are  a  large  number  of  such 
mixtures,  varying  both  in  composition  and  in  the  relative  proportion 
of  their  separate  constituents.     The  A.  C.  E.  mixture  is  composed  of: 

Alcohol,  I  part 

Chloroform,  2  parts 

Ether,  3  parts 

A  mixture  somewhat  similar  to  this,  known  as  the  Billroth  mixture, 

Alcohol,  I  part 

Ether,  i  part 

Chloroform,  3  parts 

The  C.  E.  or  Vienna  mixture  contains: 

Chloroform,  i  part 

Ether,  3  parts 

Schleich's  mixture  for  general  anesthesia  is  composed  of  ether,  chloro- 
form, and  petroleum  ether.  This  is  furnished  in  three  strengths  of 
solution,  one  for  light  narcosis,  one  for  moderate  narcosis,  and  one  for 
deep  narcosis. 

Anesthol  is  composed  of: 

Ethyl  chlorid,  17        per  cent. 

Chloroform,  35.89  per  cent. 

Ether,  47  ■  10  per  cent. 

Of  these,  the  A.  C.  E.  mixture,  the  C.  E.  mixture,  and  anesthol 
are  most  used  in  this  country. 



In  point  of  safety,  mixtures  occupy  a  place  between  chloroform 
and  ether,  the  added  safety  over  chloroform  depending  mainly 
upon  the  stimulating  effect  of  the  ether.  The  comphcations  and 
dangers  that  may  arise  during  the  administration  of  these  mixtures, 
however,  are  those  met  with  from  chloroform  rather  than  from  ether, 
and,  as  a  general  principle,  mixtures  should  be  given  with  as  much 
caution  as  would  be  observed  in  the  administration  of  the  most  dan- 
gerous drug  they  contain. 

Suitable  Cases. — When  nitrous  oxid  or  ether  are  considered  inad- 
visable, a  mixture  of  chloroform  and  ether  is  the  next  choice.  Thus 
in  children  and  in  persons  over  sixty,  in  the  fat  and  plethoric,  in  cases 
suffering  from  chronic  lung  trouble,  as  emphysema,  bronchitis,  etc., 
in  advanced  cardiac  disease  with  lack  of  compensation,  in  atheroma, 
in  alcoholics,  in  those  with  renal  disease,  and  in  cerebral  operations 
mixtures  are  most  useful.  Being  agreeable  to  take,  they  are  often 
used  as  a  means  of  obtaining  primary  anesthesia  to  ether  when  nitrous 
oxid  or  ethyl  chlorid  are  unavailable. 

Apparatus. — Mixtures  containing  chloroform  should,  always  be 
given  by  the  open  method,  and  for  this  purpose  some  such  mask  as 
the  Esmarch  or  Schimmelbusch,  previously  described  (see  page  lo), 
should  be  used. 

Administration. — The  same  general  rules  and  principles  that 
govern  the  administration  of  chloroform  should  be  followed  in  the  use 
of  mixtures.  They  should  always  be  given  with  the  patient  in  a 
recumbent  position.  The  inhalation  is  begun  gradually  with  the 
admixture  of  plenty  of  air.  Small  quantities  of  the  anesthetic  fre- 
quently repeated  are  to  be  used  in  preference  to  a  few  large  doses. 

The  anesthesia  produced  by  mixtures  is  only  a  slight  modification 
of  chloroform  narcosis.  On  account  of  the  stimulating  effect  of  the 
ether,  the  pulse  is  fuller  and  more  rapid,  respirations  are  deeper,  and 
the  whole  appearance  of  the  patient  is  better  than  when  chloroform 
alone  is  used.  Dangerous  signs,  should  they  appear,  are  not  quite 
so  abrupt  as  with  chloroform  and  may  usually  be  detected  before  a 
serious  or  hopeless  condition  supervenes. 


Intubation  Anesthesia. — In  operations  about  the  mouth,  such 
as  is  required,  for  instance,  in  removal  of  the  tongue,  repair  of  a  cleft 
palate,  resection  of  the  jaw,  etc.,  the  administration  of  the  anesthetic 
by  means  of  tubes  passed  into  the  pharynx  through  the  nose,  known 



as  Crile's  method,  will  be  found  of  great  service.  The  advantages  are 
that  the  anesthetist  and  inhaler  are  removed  from  the  seat  of  opera- 
tion so  that  they  in  no  way  interfere  with  the  operator,  and  the  anes- 
thetic may  be  administered  continuously,  as  it  is  not  necessary  to 
delay  or  stop  the  operation  every  little  while  in  order  to  get  the  patient 
well  under,  as  is  the  case  when  the  ordinary  interrupted  form  of  anes- 
thesia is  employed.  As  the  pharynx  is  packed  with  gauze,  aspiration 
of  mucus  or  blood  from  the  site  of  operation  is  avoided,  nor  is  there 
vomiting  or  coughing  up  of  blood  that  may  have  collected  in  the  back 
of  the  pharynx. 

Apparatus. — The  apparatus  consists  of  two  rubber  tubes  of  a  size 
that  will  comfortably  pass  through  the  nares,  each  about  8  inches 

Fig.  27. — Showing  the  method  of  inserting  the  tubes  and  packing  the  pharynx  for 

intubation  anesthesia. 

(20  cm.)  long,  preferably  cut  at  their  distal  ends  at  an  acute  angle,  and 
furnished  with  side  openings.  The  upper  ends  of  the  tubes  are 
connected  to  the  two  arms  of  a  Y-shaped  glass  tube,  to  the  long  arm 
of  which  is  attached  by  means  of  a  third  piece  of  rubber  tubing  a  fun- 
nel lightly  packed  with  gauze. 

Technic. — After  full  anesthesia  has  been  obtained  in  the  usual 
way,  a  mouth  gag  is  inserted,  the  throat  is  well  cleared  of  mucus  by 
means  of  small  gauze  swabs,  and  the  two  tubes,  well  lubricated,  are 
carefully  passed  through  the  nares  and  down  to  the  epiglottis  with 
their  pointed  ends  directed  downward  and  forward.     The  tongue  is 


then  drawn  well  forward  and  the  whole  pharynx  is  firmly  packed  with 
a  single  piece  of  gauze  in  such  a  way  that  the  packing  does  not  ob- 
struct the  lateral  fenestras  or  ends  of  the  tubes  (Fig.  27).  Care 
should  be  taken  at  this  stage  to  hsten  at  the  ends  of  the  tubes  in  order 
to  make  sure  that  the  patient  is  breathing  properly.  If  he  is  not, 
the  gauze  should  be  promptly  removed  and  the  pharynx  repacked. 
As  soon  as  regular  breathing  is  established  through  the  tubes,  the 
funnel  is  connected  and  the  anesthetic  is  continued  by  the  drop 

Intratracheal  Insufflation  Anesthesia. — Intratracheal  in- 
sufHation  anesthesia,  tirst  suggested  by  Meltzer  and  Auer,  con- 
sists essentially  in  the  introduction  deep  into  the  trachea  of  a 
flexible  tube  with  a  diameter  considerably  less  than  the  lumen 
of  the  trachea  and  the  forcing  of  a  current  of  air  and  ether  vapor 
through  the  tube,  the  space  between  the  tube  and  trachea  per- 
mitting the  return  of  air  from  the  lungs.  This  method  of  anes- 
thesia was  originally  adopted  to  supply  a  positive  pulmonary  pres- 
sure for  operations  upon  the  thoracic  viscera,  the  resistance  to  the 
return  of  air  through  the  trachea  being  sufficient  to  prevent  the 
lungs  from  collapsing  when  the  thorax  is  opened.  For  this  pur- 
pose it  has  largely  replaced  the  various  differential  pressure 

Intratracheal  insufflation  is,  furthermore,  of  special  value  in  opera- 
tions about  the  mouth,  tongue,  throat,  jaws,  and  nose  as  the  continu- 
ous reflux  air  current  prevents  the  aspiration  of  blood,  mucus,  vom- 
itus,  or  other  foreign  matter  from  the  pharynx  into  the  trachea.  It 
is  also  indicated  in  cases  where  normal  respiration  is  interfered  with, 
and  in  operations  about  the  neck,  head,  or  face  it  permits  the  operator 
to  work  in  an  unobstructed  field.  The  easy,  even  anesthesia  pro- 
duced by  this  method,  the  marked  absence  of  shock  and  post- 
operative vomiting  attending  its  use,  and  the  fact  that  the  dosage 
may  be  accurately  regulated  has  led  some  surgeons  to  employ  it  as  a 
routine  in  preference  to  the  ordinary  inhalation  methods. 

WTiile  some  accidents  have  attended  the  use  of  insufflation 
anesthesia,  they  have  been  due  to  faulty  technic.  If  an  approved 
form  of  apparatus  is  used  and  certain  cautions  are  observed,  there  is 
no  danger.  The  apparatus  should  alwa}-s  be  provided  with  a  safety 
valve  to  guard  against  overpressure  and  there  must  be  no  chance  of 
Hquid  ether  entering  the  tracheal  tube.  Furthermore,  before  begin- 
ning the  insufflation,  the  operator  must  assure  himself  that  the  tube 
is  in  the  trachea  and  not  in  the  esophagus,  that  the  tube  is  not  intro- 



duced  beyond  the  bifurcation  of  the  trachea,  and  that  during  the 
insertion  of  the  tube  the  pharynx  and  trachea  are  not  injured. 

Apparatus. — There  are  several  good  intratracheal  insufflation 
machines  on  the  market,  such  as  Elsberg's,  Janeway's,  and  Boothby's, 
which  are  elaborate  in  their  completeness.  A  very  simple  and  inex- 
pensive apparatus  (Fig.  28),  which  answers  all  purposes,  is  described 
by  Meltzer  (Keen's  Surgery,  Vol.  VI)  as  follows: 

"By  means  of  a  glass-blower's  foot-bellows  (B)  air  is  driven 
through  a  system  of  branching  tubes  into  the  intratracheal  tube 
In.-T) .     The  first  branching  of  the  tubes  is  introduced  for  the  purpose 

Fig.  28. — Apparatus  for  intratracheal  insufflation  anesthesia   (Meltzer  in  Keen's 

Surgery) . 

of  regulating  the  interruption  of  the  air-stream.  From  the  right 
branch  a  tube  is  led  off  laterally,  carrying  a  stopcock  (St.  3),  which  is  to 
be  used  for  the  interruptions  of  the  air-current.  During  the  opening 
of  the  stopcock  a  part  of  the  air-current  continues  through  the  left 
tube,  thus  preventing  too  great  a  reduction  of  the  pressure,  which  is 
undesirable.  By  means  of  a  screw-clamp  (S.C.)  the  amount  of  air 
which  is  to  pass  through  the  left  tube  can  be  regulated;  a  narrowing 
of  this  tube  causes  a  greater  collapse  of  the  lung  during  the  interrup- 
tion. The  second  branching  of  the  tubes  is  introduced  for  the  pur- 
pose of  regulating  the  anesthesia.  The  ether  bottle  (E)  is  interpo- 
lated in  the  left  branch;  the  right  branch  runs  uninterrupted  outside 
of  the  bottle  to  unite  with  the  part  of  the  left  tube  which  comes  from 
the  ether  bottle.     When  the  stopcock  in  the  right  branch  (St.  2)  is 



closed,  all  the  air  passes  through  the  ether  bottle;  when,  instead,  both 
stopcocks  in  the  left  branch  (St.  i  and  St.  4)  are  closed,  only  pure  air 
reaches  the  intratracheal  tube,  and  when  all  three  stopcocks  are 
open  only  one-half  of  the  air  is  saturated  with  the  anesthetic.  By 
partial  closing  of  the  stopcocks  various  degrees  of  anesthesia  can  be 
obtained.  The  third  opening  in  the  ether  bottle  carries  a  tube  with 
a  funnel  (F)  through  which  the  bottle  is  filled  with  the  anesthetic; 
the  tube  is  otherwise  kept  tightly  closed  by  means  of  a  screw-clamp 
(S.C.).  All  three  rubber  stoppers  are  firmly  and  permanently  wired 
down  to  resist  various  pressures.  When  the  ether  bottle  is  to  be 
refilled  during  insufflation,  both  stopcocks  on  the  left  side  are  closed, 
while  the  one  on  the  right  side  is  open." 

"The  tube  which  connects  the  anesthesia  circle  of  tubing  with  the 
intratracheal  tube  (In.-T)  carries  two  lateral  tubes;  one  is  connected 
with  a  manometer  (M),  which  needs  no  description,  and  the  other 
leads  to  a  safety  valve  (S.V.)  of  a  simple  construction.     To  the  rubber 

Fig.   29. — Jackson's  direct  view  laryngoscope. 

tubing  is  attached  a  graduated  glass  tube,  the  lower  end  of  which  is 
immersed  under  the  surface  of  the  mercury  in  this  bottle  to  a  depth 
corresponding  to  the  pressure  which  is  desired  for  the  intratracheal 
insuffiation.  For  instance,  if  the  pressure  should  be  not  more  than 
20  mm.  of  mercury,  the  glass  tube  is  immersed  just  20  mm.  below  the 
surface  of  the  mercury.  The  glass  tube  is  kept  in  the  desired  place 
by  means  of  a  rubber  ring  resting  upon  the  opening  of  the  mercury 
bottle.  This  device  gives  great  safety  to  the  working  of  the  method. 
No  matter  how  strong  and  irregular  the  bellows  is  worked,  the  intra- 
tracheal pressure  could  never  rise  above  the  one  arranged  for;  the 
surplus  of  air  escapes  through  the  tube  from  under  the  mercury." 
The  tracheal  tube  should  be  flexible  and  elastic,  about  14  inches 


(35  cm.)  long,  with  a  mark  lo  1/2  inches  (27  cm.)  from  the  distal  end 
and  with  the  opening  preferably  at  the  end.  A  silk  woven  catheter, 
No.  22  to  24  French,  and  for  children  of  a  correspondingly  small  size, 
is  frequently  used.  There  will  be  required  in  addition  a  mouth-gag 
and  a  Jackson's  direct  view  laryngoscope  (Fig.  29).  Elsberg  has 
devised  a  special  bit  or  holder  to  keep  the  tube  from  sHpping  up  or 
down  after  it  has  been  properly  introduced,  but,  in  its  absence, 
adhesive  plaster  may  be  employed  for  this  purpose. 

Asepsis. — The  tracheal  tube  and  the  laryngoscope  must  be  sterile. 

Preparations  of  the  Patient. — The  patient  is  prepared  as  for  any 
anesthesia  (see  page  2)  and  is  given  morphin  gr.  1/6  (0.0108  gm.) 
and  atropin  gr.  i/ioo  fo. 00065  S^^-)  by  hypodermic  half  an  hour 
before  the  operation. 

Technic. — The  patient  is  first  etherized  in  the  usual  way  and  is 
placed  upon  the  operating-table  with  his  head  hanging  over  the  edge 
in  which  position  it  is  supported  by  an  assistant  (see  Fig.  474), 
the  patient's  mouth  being  held  open  by  a  mouth-gag.  ^  The 
Jackson  laryngoscope  is  then  introduced  (for  the  technic  of  this  see 
page  398),  and,  with  the  epiglottis  pulled  forward  by  the  beak  of  the 
instrument  so  that  a  good  view  of  the  larynx  is  obtained,  the  tracheal 
catheter,  wet  in  cold  water,  is  inserted. .  No  force  should  be  employed 
in  introducing  the  catheter,  and,  as  soon  as  it  is  well  in  the  larynx, 
the  tubular  speculum  is  removed.  The  catheter  is  then  pushed  for- 
ward until  it  meets  a  resistance  which  is  generally  the  right  bronchus. 
The  catheter  is  then  withdrawn  2  to  2  1/2  inches  (5  to  6  cm.)  until  the 
mark  on  the  catheter  is  at  the  patient's  teeth.  The  operator  must 
be  certain  that  the  catheter  is  in  the  patient's  trachea  and  not  in  the 
esophagus.  The  catheter  is  finally  fixed  in  place,  and,  after  the 
apparatus  is  properly  connected,  the  insufflation  of  the  air  and  ether 
vapor  is  commenced.  The  vapor  at  first  should  be  blown  in  under 
sHght  pressure,  that  is,  about  10  mm.  of  mercury  and  then  under 
higher  pressure — 15  to  20  mm.  of  mercury.  The  air  current  should  be 
interrupted  5  to  6  times  a  minute  by  opening  the  vent  for  that  purpose 
a  second  or  two  at  a  time.  The  anesthesia  is  pushed  to  complete 
muscular  relaxation  and  abohtion  of  reflexes,  and,  when  the  desired 
degree  of  narcosis  is  obtained,  the  dose  of  ether  should  be  kept  uni- 
form, as  the  degree  of  anesthesia  from  a  certain  dose  is  practically 
stationary.  At  all  times  it  should  be  seen  that  there  is  a  free  passage 
for  air,  and  the  tongue  should  not  be  allowed  to  fall  back  and  produce 
any  obstruction.  A  spasm  of  the  glottis  may  in  some  cases  be  the 
cause  of  obstruction;  if  so.  full  anesthesia  will  relieve  the  condition. 


The  color  and  respirations  of  the  patient  should  be  carefully  watched, 
and,  if  the  latter  become  shallow  and  infrequent,  the  anesthetic 
should  be  diminished. 

For  ordinary  cases,  the  manometer  is  kept  at  15  to  20  mm.  of 
mercury.  In  operations  on  the  thoracic  viscera,  the  pressure  will 
depend  upon  the  distention  of  the  lung  desired;  it  should,  however, 
never  be  higher  than  50  mm.  of  mercury.  If  the  catheter  proves  too 
small  to  keep  the  lung  inflated  when  the  thorax  is  opened,  Meltzer 
recommends  that  pressure  be  made  over  the  middle  of  the  thyroid 
cartilage  every  few  moments. 

At  the  completion  of  the  operation,  the  ether  is  discontinued  and 
pure  air  is  insufflated  for  a  moment  or  two  before  the  tube  is  with- 
drawn in  order  to  remove  as  much  of  the  anesthetic  vapor  as  possible 

Fig.  30. — The  Trendelenburg  apparatus  for  tracheal  anesthesia. 

Anesthesia  Through  a  Tracheal  Opening. — In  some  opera- 
tions upon  the  tongue,  larynx,  or  pharynx  it  becomes  necessary  to 
administer  the  anesthetic  through  an  opening  in  the  trachea. 

Apparatus. — For  this  purpose  a  Hahn  or  a  Trendelenburg 
cannula  is  employed.  These  instruments  consist  essentially  of  a 
metal  funnel,  covered  or  filled  with  gauze  upon  which  the  anesthetic 
is  dropped,  and  connected  with  a  special  tracheotomy  tube  by  means 
of  a  piece  of  tubing.  The  tracheal  tube  of  the  Hahn  apparatus  is 
surrounded  by  a  flat  dried  sponge  fastened  securely  in  place,  which, 
when  wet,  swells  up  and  acts  as  a  tampon,  preventing  blood  from  de- 
scending along  the  side  of  the  tube.  The  same  result  is  obtained  with 
the  Trendelenbm-g  instrument  (Fig.  30)  by  surrounding  the  lower 
portion  of  the  cannula  with  a  delicate  air  bag,  which  is  gently  inflated 



by  compressing  an  inflating  bulb  supplied  with  the  apparatus  as  soon 
as  the  tracheotomy  tube  is  in  place  (Fig.  31). 

Technic. — A  preliminary  tracheotomy  is  first  performed  (see 
page  389).  The  tracheal  tube  is  then  introduced  into  the  opening, 
care  being  taken  to  see  that  the  tamponade  is  effective,  so  as  to  pre- 
vent blood  from  entering  the  trachea.  The  tube  to  convey  the  anes- 
thetic vapor  from  the  funnel  is  then  attached  to  the  tracheal  cannula, 
and  the  anesthetic  is  administered  by  dropping  chloroform  on  the 
gauze  of  the  inhaler. 

Intravenous  General  Anesthesia. — Burkhardt  in  1909  de- 
vised a  method  of  producing  general  narcosis  by  administering 
ether  intravenously  in  a  normal  salt  solution.  Since  then  the 
method  has  been  given  a  trial  by  a  number  of  operators  abroad  and 

Fig.  31. — Showing  the  tracheal  cannula  in  place. 

by  a  few  in  this  country,  but  further  experience  will  be  necessary  be- 
fore its  true  value  can  be  determined.  From  our  present  knowledge 
it  is  not  probable  that  intravenous  etherization  will  ever  supplant 
the  inhalation  method  as  a  routine.  In  certain  operations,  as  those 
about  the  face,  upper  air  passages,  mouth,  tongue,  and  neck, 
the  absence  of  a  mask  near  the  field  of  operation  and  the  even  and 
uninterrupted  anesthesia  that  is  produced  by  this  method  is  of 
undoubted  advantage.  Furthermore,  the  stimulating  effect  of  a 
continuous  saline  infusion  makes  the  method  one  of  special  value  in 
ill-nourished,  debilitated,  or  cachectic  subjects.  On  the  other  hand, 
there  are  the  dangers  of  sepsis,  thrombosis,  embolism,  and  pulmonary 
edema  if  all  the  details  of  the  technic  are  not  carefully  observed. 
When  properly  administered  it  is  claimed  that  the  anesthesia  is 
rapidly  obtained,  that  there  is  seldom  any  stage  of  excitement,  that 



pulmonary  irritation  and  nausea  are  absent,  and  that  the  recovery 
from  the  anesthesia  is  prompt  and  without  discomfort.  According  to 
Kummell  intravenous  anesthesia  is  contraindicated  in  the  presence  of 
arterio-sclerosis,  myocarditis,  and  general  plethora. 

In  the  early  cases  in  which  this  method  was  employed,  an  inter- 
rupted form  of  anesthesia  was  given,  that  is,  a  quantity  of  ether  solu- 
tion sufficient  to  get  the  patient  under  was  in- 
fused and  the  flow  was  then  stopped,  the  infu- 
sion being  continued  when  the  patient  com- 
menced to  show  signs  of  coming  out.  The 
uneven  anesthesia  this  produced  and  the  fact 
that  some  cases  of  venous  thrombosis  and  pul- 
monary embolism  were  reported  as  a  sequel  led 
to  the  adoption  of  a  continuous  infusion  as  the 
only  safe  method. 

Apparatus. — An  apparatus,  such  as  described 
by  Rood  {British  Medical  Journal,  Oct.  21, 
191 1),  which  will  permit  a  continuous  but  slow 
flow  of  solution  is  required.^  The  apparatus 
should  consist  of  (i)  a  glass  reservoir  with  a  ca- 
pacity of  3  pints  (1500  c.c.)  supported  upon  a 
stand  at  a  height  of  8  feet  (240  cm.)  from  the 
floor,  (2)  a  glass  dripping  chamber  with  a  capa- 
city of  8  ounces  (250  c.c.)  and  (3)  a  warming 
chamber  surrounded  by  a  jacket  containing 
water  at  a  temperature  of  100°  F.  (38°  C.)  (Fig. 
32).  When  the  apparatus  is  working  the  solu- 
tion drips  from  the  pipette  leading  from  the  res- 
ervoir into  the  indicator,  the  lower  half  of  which 
is  filled  with  solution  and  the  upper  half  with  air. 
A  tap  below  the  indicator  controls  the  rate  of 
flow,  the  rate  at  which  the  solution  drips  from 
the  pipette  being  an  index  of  the  rate  at  which 
it  will  enter  the  vein. 

Instruments. — The  operator  will  require  a 
scalpel,  a  pair  of  blunt-pointed  scissors,  thumb  forceps,  an  aneurysm 
needle,  a  needle  holder,  curved  needles  with  a  cutting  edge,  and  No. 
2  plain  catgut  (Fig.  1,2,). 

Solutions. — Ether  is  used  in  a  5  per  cent,  solution  in  normal  salt 

1  In  this  country  an  apparatus  designed  by  Dr.  Honan  is  manufactured  by  the 
Knv  Scheerer  Co.  of  New  York. 

Fig.  32 — Appara- 
tus for  intravenous 



solution  by  Burkhardt  and  in  a  7.5  per  cent,  solution  by  Rood.  Hedo- 
nal  and  paraldehyde  have  also  been  used  with  success.  Fedoroff 
employs  a  0.75  per  cent,  solution  of  hedonal  in  normal  salt  solution. 
The  objection  to  the  use  of  this  drug  is  the  length  of  time  the  hypnotic 
effect  persists  when  large  amounts  are  administered.  Noel  and  Sout- 
tar  {Annals  of  Surgery,  January,  1913)  first  called  attention  to  the 
anesthetic  effects  of  paraldehyde  when  given  intravenously.  Honan 
and  Hassler  {Medical  Record,  Feb.  8,  1913)  employ  paraldehyde 
2  1/2  per  cent,   and  ether  3  per  cent,  in  normal  salt  solution. 

Temperature. — The  solution  should  be  given  at  a  temperature  of 
about  that  of  the  body. 

Fig.  33. — ^Instruments  for  intravenous  anesthesia,  i,  Scalpel;  2,  blunt- 
pointed  scissors;  3,  thumb  forceps;  4,  aneurysm  needle;  5,  needle  holder;  6, 
curved  needles;  7,  No.  2  plain  catgut. 

Quantity. — The  amount  of  solution  used  will  depend  upon  the  age 
and  condition  of  the  patient  and  the  length  of  anesthesia.  Usually 
from  6  to  25  ounces  (200  to  800  c.c.)  of  solution  will  be  required. 

Site  of  Injection. — One  of  the  most  prominent  veins  at  the  bend  of 
the  elbow — preferably  the  median  basilic — is  chosen  for  the  infusion. 

Preparations  of  Patient. — It  is  advisable  to  give  the  patient  hypo- 
dermically  an  hour  before  the  operation  morphin  gr.  1/6  (0.0108  gm.), 
atropin  gr.  i/ioo  (0.00065  gm.),  and  scopolamin  gr.  i/ioo  (0.00065 
gm).  All  clothing  should  be  removed  from  the  arm  chosen  for  the 
infusion  and  the  arm  should  be  bandaged  to  a  well-padded  splint  so 
that  the  infusion  cannula  cannot  be  disturbed  by  movements  of  the 


Asepsis. — The  solution  must  be  absolutely  sterile.  The  instru- 
ments are  sterilized  by  boiling.  The  site  for  the  infusion  is  shaved 
and  thoroughly  cleansed  twenty-four  hours  before  the  operation, 
and  is  then  dressed  with  sterile  gauze.  At  the  time  of  operation 
the  skin  is  painted  with  tincture  of  iodin. 

Technic. — A  tourniquet  is  placed  about  the  arm  above  the  site  of 
injection.  Under  infiltration  anesthesia  with  a  0.2  per  cent,  solution 
of  cocain  or  a  i  per  cent,  novocain  solution  the  median  cephalic  or  the 
median  basilic  vein  is  exposed  through  a  small  incision.  The 
distal  porton  of  the  vein  is  ligated,  the  proximal  portion  is  in- 
cised, and  the  cannula  inserted  with  the  solution  flowing  as  described 
under  intravenous  infusion  (page  138).  The  constriction  is  then 
removed  from  the  arm  and  the  ether  solution  is  allowed  to  run,  at  first 
rapidly  until  anesthesia  is  induced,  and  then  drop  by  drop,  being 
guided  by  the  depth  of  anesthesia. 

It  usually  requires  from  four  to  ten  minutes  to  induce  full  anes- 
thesia, using  3  to  6  ounces  (100  to  200  c.c.)  of  solution.  After 
anesthesia  is  obtained  the  flow  of  solution  should  be  at  about  the 
rate  of  40  to  60  drops  per  minute.  Should  edema  of  the  eyelids 
appear  at  any  time,  the  infusion  should  be  temporarily  stopped. 
During  the  anesthesia  the  anesthetist  must  take  the  same  pre- 
cautions to  maintain  unobstructed  air  passages  as  with  inhalation 

At  the  completion  of  the  operation  the  cannula  is  removed,  the 
vein  ligated  with  catgut,  and  the  wound  sutured.  A  sterile  dressing 
is  then  applied. 

Rectal  Anesthesia. — It  consists  in  producing  narcosis  by  means 
of  warm  ether  vapor  slowly  forced  into  the  rectum.  This  method 
was  employed  in  1847  by  Roux.  Later,  in  1884,  it  was  taken  up  by 
Molliere  and  in  this  country  by  Dr.  Weir  and  Dr.  Bull,  but  it  never 
came  into  general  use.  In  the  early  cases  coHcky  pains,  diarrhea, 
bloody  stools,  and  painful  distention  of  the  intestine  were  frequently 
observed.  These  symptoms,  no  doubt,  were  in  many  instances  due 
to  faulty  methods  of  administering  the  anesthetic,  and  with  the 
improved  technic  of  Cunningham  the  method  has  given  better  results. 

Though  it  cannot  be  said  to  be  free  from  risks,  rectal  anesthesia  has 
a  definite  place  among  the  methods  of  anesthetizing  at  our  disposal. 
Its  greatest  field  of  usefulness  is  in  cases  of  extreme  pulmonary  or 
bronchial  involvement  and  empyema,  and  in  operations  about  the 
face,  mouth,  and  larynx,  where  other  means  of  anesthesia  areunsuited. 
To  the  former  class  of  cases  it  is  especially  suited  on  account  of  the 



absence  of  pulmonary  or  bronchial  irritation  from  the  ether.  While 
it  is  true  that  the  greater  part  of  the  ether  is  eHminated  from  the  lungs,, 
the  direct  irritation  of  concentrated  vapor  is  overcome,  as  is  shown 
by  the  absence  of  the  bronchial  secretion,  cough,  etc.  The  method 
also  has  the  advantage  of  requiring  but  Httle  ether  to  induce  and  main- 
tain anesthesia,  and  there  is  practically  no  stage  of  excitement  or 
postoperative  nausea  and  vomiting.  On  the  other  hand,  the  induc- 
tion of  narcosis  is  slow,  and,  in  some  cases  where  the  absorptive  power 
of  the  rectum  is  hmited,  enough  of  the  drug  is  not  taken  into  the 
system  to  keep  the  patient  under,  so  that  other  means  of  anesthetizing 
must  be  utilized.  It  is  not  a  suitable  method  to  employ  in  abdominal 
operations  on  account  of  the  distention  produced,  nor  should  it  be 
used  if  the  intestines  are  inflamed  or  their  walls  weakened. 

Fig.  34. — Apparatus  for  rectal  anesthesia. 

Apparatus. — The  necessary  apparatus  consists  of  the  following: 
A  wash  bottle  to  hold  the  ether,  about  8  inches  (20  cm.)  high  and  4 
inches  (10  cm.)  in  diameter,  supplied  with  a  tight  stopper  in  which 
are  two  perforations.  Through  one  of  these  openings  a  glass  tube 
leads  to  the  bottom  of  the  bottle,  and  through  the  other  a  glass  tube, 
cut  off  flush  with  the  under  surface  of  the  stopper,  leads  out.  A 
double  cautery  bulb  is  attached  to  the  aft'erent  tube  by  a  piece  of 
rubber  tubing,  while  to  the  efferent  tube  is  connected  a  piece  of  rubber 
tubing  leading  to  a  plain  rectal  tube,  a  glass  bulb  being  interposed  be- 
tween the  rectal  tube  and  the  rubber  tubing  to  catch  any  condensed 
ether  vapor  and  prevent  it  from  entering  the  rectum.  Both  the  affer- 
ent and  the  eft'erent  tubes  should  be  of  sufficient  length  to  permit  the 


apparatus  to  be  moved  to  a  distance  from  the  patient  if  necessary. 
The  ether  bottle  is  surrounded  by  a  metal  container  holding  warm 
water.  This  should  be  kept  at  a  temperature  of  about  90°  F.  (32° 
C),  but  not  much  above,  as  the  ether  will  boil  at  96°  F.  (35°  C). 
A  thermometer  should  be  provided  for  the  purpose  of  regulating 
the  temperature.  By  compressing  the  cautery  bulb  air  is  forced 
into  the  ether  through  the  long  tube  and  leaves  the  apparatus  satu- 
rated with  warm  ether  vapor. 

Preparation  of  the  Patient. — A  thorough  cleansing  of  the  bowels  is 
absolutely  necessary,  otherwise  absorption  cannot  take  place  and  the 
first  essential  of  the  anesthesia  is  defeated.  A  cathartic  is  given  to 
the  patient  the  night  before  the  operation,  and  on  the  following 
morning  a  colonic  irrigation,  followed  by  an  ordinary  soapsuds 
enema  an  hour  before  the  operation,  complete  the  preparations. 

Technic. — The  patient  lies  upon  the  table  with  one  thigh  elevated 
upon  a  sand-bag  so  as  to  afford  room  to  insert  the  tube,  etc.  The 
bottle  is  filled  about  two-thirds  with  ether,  leaving  one-third  of  its 
capacity  for  vapor,  and  the  apparatus  is  tested  to  see  that  it  works 
properly.  The  rectal  tube,  well  lubricated,  is  inserted  8  to  10 
inches  (20  to  25  cm.)  within  the  bowel,  and  the  ether  vapor  is  forced 
in  by  means  of  gentle  compressions  of  the  rubber  bulb  every  five  to 
ten  seconds.  As  the  rectum  becomes  distended,  the  forefinger  should 
be  inserted  alongside  the  tube  into  the  bowel  to  permit  the  gases 
already  present  to  escape,  otherwise  the  absorption  of  the  vapor  is 
interfered  with;  on  complaints  of  distention,  the  superfluous  vapor 
must,  likewise,  be  allowed  to  escape. 

In  from  three  to  five  minutes  the  odor  of  the  drug  will  be  distin- 
guished in  the  patient's  breath,  and  the  patient  soon  begins  to  feel 
drowsy.  The  breathing,  at  first  rapid,  becomes  regular  and  finally 
slightly  stertorous,  and  the  patient  then  passes  into  complete  surgical 
narcosis,  generally  without  the  preliminary  stage  of  excitement.  The 
time  necessary  for  this  varies  from  five  to  fifteen  minutes,  according 
to  the  patient  and  the  absorption  power  of  the  bowel.  The  anesthetic 
cannot  be  pushed,  however,  for  the  more  the  bowel  is  distended 
beyond  a  certain  point  the  less  is  the  absorption.  As  soon  as  anes- 
thesia is  complete  it  may  be  maintained  by  gently  squeezing  the  bulb 
every  minute  or  so.  The  same  signs  as  to  the  depth  of  anesthesia, 
condition  of  the  patient,  etc.,  should  guide  the  anesthetist  as  in  the 
administration  of  pulmonary  anesthesia,  and  the  same  precautions 
about  keeping  the  tongue  and  the  jaw  forward  should  be  observed. 
At  the  completion  of  the  anesthesia,  the  rectal  tube  is  disconnected 


from  the  apparatus,  and,  by  gentle  abdominal  massage  of  the  colon, 
the  vapor  remaining  unabsorbed  is  forced  out.  This  should  be  fol- 
lowed by  a  cleansing  enema. 

OiI=ether  Colonic  Anesthesia. — Recently  Gwathmey  of  New 
York  has  developed  a  method  of  rectal  anesthesia  by  means  of  a 
mixture  of  olive  oil  and  ether  injected  into  the  rectum  to  which  he 
applies  the  name  "oil-ether  colonic  anesthesia"  (N.  Y.  Medical 
Journal,  Dec.  6,  19 13).  Up  to  the  present  writing  this  method 
of  anesthesia  has  been  used  in  something  over  100  cases  and,  while 
it  may  be  said  to  be  still  in  the  experimental  stage,  it  promises 
to  be  a  most  valuable  addition  to  the  field  of  anesthesia.  The 
method  is  especially  useful  in  operations  about  the  head  and  neck, 
though  it  has  been  used  in  a  great  variety  of  operations.  According 
to  Gwathmey,  it  is  contraindicated  in  cohtis,  hemorrhoids,  fistula  in 
ano,  or  other  pathological  conditions  of  the  lower  bowel,  and  in  most 
cases  where  ether  is  contraindicated.  Under  this  form  of  anesthesia 
there  is  complete  relaxation,  the  reflexes  remain  active,  and  there  is 
an  absence  of  nausea.  For  from  one  to  three  hours  following  the 
anesthesia  there  is  a  pain-free  period.  So  far  no  diarrhea  or  bloody 
stools  or  other  untoward  effects  have  been  observed. 

Apparatus. — The  necessary  equipment  is  very  simple,  consisting 
of  a  catheter  and  funnel  for  introducing  the  oil  and  ether  mixture  and 
two  small  rectal  tubes  for  emptying  and  irrigating  the  colon. 

Solutions  Used. — A  mixture  of  ether  in  olive  oil  is  employed  in 
the  following  strengths:  For  cases  over  fifteen  years  of  age  a  75  per 
cent,  mixture;  for  children  of  from  six  to  twelve  years  of  age  a  55  to 
65  per  cent,  mixture;  and  for  those  under  six  years  of  age  a  50  per 
cent,  mixture. 

Quantity. — One  ounce  (30  c.c.)  of  the  mixture  is  administered  for 
each  20  pounds  (8  K.)  of  weight. 

Preparations  of  Patient. — The  usual  preparations  as  for  any  anes- 
thetic are  carried  out,  and  the  colon  is  irrigated  until  the  fluid  returns 
clear.  For  adults  a  preliminary  hypodermic  injection  of  1/8  to 
1/4  gr.  (0.0081  to  0.0162  gm.)  of  morphin  and  i/ioo  gr.  (0.00065 
gm.)  of  atropin  is  given  half  an  hour  before  operation  and  at  the  same 
time  5  gr.  (0.3  gm.)  of  chloretone  in  2  drams  (8  c.c.)  of  olive  oil  and 
2  drams  (8  c.c.)  of  ether  is  introduced  into  the  rectum.  For  children 
preliminary  medication  is  generally  omitted,  as  the  weaker  solutions 
are  not  irritating  to  the  bowel. 

Technic. — The  anesthetic  mixture  is  introduced  into  the  bowel 
while  the  patient  is  in  bed  in  the  Sims  position.     The  small  catheter, 


well  lubricated,  is  inserted  a  few  inches  into  the  rectum  and  the  desired 
quantity  of  solution,  depending  upon  the  weight  of  the  patient,  is 
slowly  poured  into  the  funnel.  About  five  minutes  should  be  con- 
sumed in  introducing  8  ounces  (250  c.c),  the  quantity  generally 
required  for  an  adult  of  ordinary  size.  The  tube  should  be  left  in 
place  until  the  patient  is  partially  unconscious.  In  from  five  to 
twenty  minutes  the  anesthesia  is  estabhshed.  During  the  anesthesia 
the  anesthetist  should  keep  the  air  passages  free  and  the  jaw  well  for- 
ward and  should  keep  careful  watch  over  the  general  condition  of  the 
patient.  Should  the  patient  become  too  deeply  under  the  influence 
of  the  anesthetic,  shown  by  cyanosis,  shallow,  embarrassed  or  ster- 
torous respirations,  a  rectal  tube  is  introduced  and  2  to  3  ounces 
(60  to  90  c.c.)  of  solution  are  withdrawn. 

At  the  completion  of  the  operation,  two  small  rectal  tubes  are 
passed  well  up  in  the  bowel  and  the  latter  is  irrigated  with  cold  water 
soapsuds,  the  injection  being  made  through  one  tube  while  the  second 
one  permits  the  escape  of  the  washings.  Two  to  3  ounces  (60  to  90 
c.c.)  of  olive  oil  are  then  injected  into  the  rectum  to  be  retained  by  the 
patient,  and  the  tubes  are  withdrawn. 

Scopolamin-morphin  Anesthesia — Hypodermic  injections  of 
scopolamin  and  hyoscin  (which  is  claimed  to  be  chemically  the  same) 
have  been  used  quite  extensively  in  combination  with  morphin  to 
produce  anesthesia.  From  the  number  of  deaths  reported  from  this 
combination  when  used  in  large  enough  quantities  to  produce 
anesthesia  unaided,  it  would  appear  to  be  a  very  dangerous  form  of 
anesthesia,  and  up  to  the  present  time  it  has  a  higher  death  percent- 
age than  chloroform  or  ether.  In  small  doses,  however,  hyoscin 
and  morphin  may  be  used  with  good  results  as  an  adjunct  to  local 
or  general  anesthesia.  In  such  cases  they  can  be  given  as  follows: 
Hyoscin,  gr.  i/ioo  (0.00065  S^-)  ^.nd  morphin,  gr.  1/6  to  1/4 
(0.0108  to  0.0162  gm.)  by  h}^odermic,  one  hour  to  two  hours  before 
operation.  This  combination  is  more  efl&cacious  than  morphin  alone, 
and  has  the  effect  of  producing  a  drowsy  state  and  even  sleep,  which 
may  last  five  to  six  hours  after  the  operation.  It  is  contraindicated 
in  patients  with  heart  disease  or  when  there  is  a  tendency  to  pulmon- 
ary edema.  In  the  young  and  the  aged  hyoscin  and  morphin  should 
be  used  with  great  caution. 


The  accidents  and  dangers  that  may  arise  during  the  adminis- 
tration of  anesthetics  are  connected  with  the  respiratory  or  circulatory 


systems  and  include  asphyxiation,  respiratory  paralysis,  and  cardiac 
paralysis.  Theoretically,  the  dangers  of  nitrous  oxid,  ether,  and 
ethyl  chlorid  are  those  to  be  expected  from  failure  of  the  respiratory 
centers,  while  the  accidents  from  chloroform  narcosis  are  primarily 
those  occurring  as  the  result  of  the  depressing  effects  of  the  drug  upon 
the  circulation.  Practically,  however,  in  severe  cases  failure  of  the 
respiratory  centers  and  circulatory  paralysis,  if  not  coincident,  pre- 
cede or  follow  one  another  in  such  rapid  sequence  that  it  is  often 
impossible  to  distinguish  between  the  two  or  to  determine  which  is 
the  primary  cause,  and  treatment  must  be  directed  toward  both 

Accidents  may  be  avoided  in  the  great  majority  of  cases  if  proper 
precautions  are  taken  beforehand  in  the  preparation  of  the  patient 
and  due  care  is  observed  in  the  administration  of  the  anesthetic. 
These  points  have  already  been  considered,  but  it  may  not  be  out  of 
place  to  emphasize  by  repetition  the  most  important  of  them.  Never 
allow  the  patient  to  have  food  within  three  hours  of  the  time  of  anes- 
thesia. See  that  all  foreign. bodies,  false  teeth,  plates,  etc.,  which 
might  fall  into  the  throat  and  obstruct  the  respiratory  passages  are 
removed  beforehand,  and  that  tight  bandages  or  clothing  that  might 
constrict  the  neck  or  chest  are  loosened.  When  relaxation  occurs, 
turn  the  patient's  head  to  one  side  to  allow  mucus  and  saHva  to  flow 
from  the  mouth,  and  see  that  the  tongue  does  not  fall  back  in  the 
throat  and  act  as  an  obstruction.  The  anesthetist  must  devote  his 
entire  attention  to  the  anesthesia,  taking  particular  care  to  watch  the 
respirations,  at  the  same  time  not  forgetting  to  give  due  attention  to 
the  pulse,  the  condition  of  the  eye  reflexes,  and  the  general  appearance 
of  the  patient.  The  assistant  chosen  for  this  duty  should  be  a  person 
of  large  experience  in  the  administration  of  anesthetics  so  that  he 
may  be  competent  to  interpret  danger  signs  before  they  proceed  too 
far.  If  there  is  any  doubt  as  to  the  meaning  of  a  sudden  change  in  the 
patient's  condition  or  of  unusual  symptoms,  it  is  always  better  to  err 
on  the  safe  side  and  allow  the  patient  to  partly  recover  than  to  induce 
a  deeper,  and  what  may  be  a  dangerous,  state  of  narcosis. 

Asphyxiation. — It  is  characterized  by  a  moderate  cyanosis 
or  a  marked  lividity  of  color  and  gasping  respirations.  It  may 
be  only  transient,  or  it  may  become  progressively  worse  and 
severe.  Such  a  condition  should  be  promptly  treated  by  re- 
moval of  the  cause  which  will  be  found  to  be  some  one  of  the  fol- 
lowing: coughing,  struggling,  locking  of  the  Jaws,  awkward  posi- 
tion of  the  patient,  an  improper  holding  of  the  cone,  the  so-called 




"  forgetfulness  to  breathe,"  falling  back  of  the  tongue  and  epiglottis, 
obstruction  to  the  air  passages  by  blood,  mucus,  saliva,  or  foreign 
bodies,  partial  or  complete  occlusion  of  the  nose  from  deformities  of 
the  bones  and  nasal  growths,  or  from  collapse  and  falling  in  of  the 
ake  nasi  during  inspiration  under  deep  narcosis. 

Treatment.— Cyanosis  due  to  coughing  or  struggling  may    be 
overcome  by  simply  removing  the  inhaler  and  permitting  the  patient 

Fig.  35. — Method  of  holding  the  jaw  forward. 

to  get  a  breath  of  fresh  air.  When  the  position  of  the  patient  is 
responsible,  it  should  be  corrected  without  delay.  If  the  cyanosis 
be  due  to  obstruction  or  partial  occlusion  of  the  nares,  the  mouth 
should  be  kept  sufficiently  open  by  means  of  a  mouth-gag  to  permit 
the  entrance  of  the  necessary  amount  of  air.  "Forgetting  to 
breathe"  is  met  by  removing  the  inhaler  and,  after  waiting  a  moment, 

Fig.  36. — Showing  the  method  of  drawing  the  tongue  and  epiglottis  forward. 

the  patient  will  in  the  majority  of  cases  take  a  breath.  If  this  is  not 
sufficient,  a  sharp  slap  upon  the  sternum  with  a  wet  towel  or  a  momen- 
tary compression  of  the  sternum  is  frequently  all  that  is  necessary. 
Failing  by  these  means,  the  jaws  should  be  held  apart  and  rhythmic 
traction  exerted  upon  the  tongue  to  excite  a  reflex  inspiration. 

Obstruction  caused  by  the  falling  back  of  the  tongue  and  epiglot- 



tis  is  corrected  by  properly  holding  the  lower  jaw  forward  (Fig.  35), 
or  by  traction  upon  the  tongue  by  means  of  tongue  forceps  or  a  silk 
suture.  The  most  effective  means  for  overcoming  obstruction  from 
this  cause  is  to  pass  the  index  finger  into  the  mouth  over  the  base 
of  the  tongue  and  hook  it  forward  together  with  the  epiglottis 
(Fig.  3^)- 

When  the  asphyxial  symptoms  are  due  to  obstruction  by  collec- 
tions of  fluid  in  the  throat  or  foreign  bodies,  the  patient's  head  should 
be  turned  to  one  side,  the  jaws  forced  open,  and  the  air  passages 
cleared.  Sohd  bodies  may  be  removed  by  the  finger  or  forceps.  If 
this  is  not  possible,  tracheotomy  (page  424)  should  be  performed 
without  hesitation. 

In  any  case  of  asphyxia,  if  the  cyanosis  is  severe  and  grows  pro- 

FiG.  37. — Artificial  respiration   (inspiration).     Note  the  assistant's  hands  ready 
to  make  counterpressure  over  the  lower  portion  of  the  chest. 

gressively  worse  in  spite  of  the  above  line  of  treatment,  the  anesthetic 
and  the  operation  should  be  discontinued  while  artificial  respiration, 
combined  with  inhalations  of  oxygen,  is  carried  out.  This  is  effec- 
tively performed  by  a  combination  of  the  Sylvester  and  Howard 
methods,  or  by  the  use  of  Meltzer's  insufflation  apparatus  or  some 
one  of  the  machines  made  especially  for  performing  artificial  respira- 
tion. Any  of  the  methods  of  artificial  respiration  are  useless,  how- 
ever, as  long  as  there  is  any  obstruction  in  the  air  passages,  and 
these  should  always  be  first  cleared  out,  as  previously  directed. 

In   the    absence    of    special    apparatus,  artificial    respiration  is 
carried  out  as  follows:     The  foot  of  the  operating-table  is  raised 



upon  a  stool  and  the  patient  is  slid  down  so  that  the  head  hangs 
partly  over  the  edge.  The  anesthetist,  standing  at  the  patient's 
head,  takes  a  firm  hold  just  below  the  elbows  and  draws  the  arms 
upward  and  outward  until  they  are  very  nearly  perpendicular  above 
the  head  (Fig.  37).  This  thoroughly  expands  the  chest  and  pro- 
duces an  inspiration.  The  arms  are  maintained  in  this  position  for 
a  second  or  two,  to  allow  the  air  to  thoroughly  expand  the  lungs. 
Expiration  is  produced  by  the  reversal  of  the  above  maneuver, 
bringing  the  arms  downward  with  firm  pressure  against  the  chest 
wall,  while  at  the  same  time  an  assistant,  with  palms  of  the  hands 
outstretched  over  the  margins  of  the  ribs  and  epigastrium,  presses 

Fig.  38. — Artificial  respiration   (expiration).     The  operator  brings  the   patient's 
arms  firmly  against  the  chest  while  the  assistant  makes  counterpressure. 

upward  toward  the  diaphragm  (Fig.  38).  This  counterpressure 
prevents  the  effects  of  the  expiratory  maneuver  being  lost  upon 
the  diaphragm  and  abdominal  viscera.  After  another  second  or 
so,  the  assistant  suddenly  releases  the  lower  portion  of  the  chest  and 
at  the  same  time  elevation  of  the  arms  is  again  performed.  The 
movements  producing  artificial  respiration  should  be  made  as  nearly 
as  possible  at  the  rate  of  normal  respiration,  certainly  not  over  twenty 
times  a  mmute.  As  an  adjunct  to  the  above,  forcible  dilatation  of 
the  sphincter  ani  may  be  performed  for  the  purpose  of  exciting  reflex 

A  favorable  response  to  treatment  is  denoted  by  a  gradual  return 
of  the  natural  color,  at  first  feeble  gasps  and  then  stronger  attempts  at 


respiration,  and  a  return  of  the  pulse  at  the  wrist.  If,  after  five  or 
ten  minutes,  there  is  no  response  to  the  treatment,  the  prognosis  is 
exceedingly  bad,  but  the  artificial  respiration  should  be  persisted  in 
for  at  least  half  an  hour.  Deaths  from  asphyxia  alone  during  anes- 
thesia can  be  prevented  in  nearly  all  cases  by  following  the  sugges- 
tions and  the  treatment  above  described. 

Respiratory  Paralysis. — This  is  a  more  serious  condition.  In 
the  first  stages  of  anesthesia  it  may  be  due  to  a  spasm  of  the  glottis, 
diaphragm,  or  respiratory  muscles  through  reflex  irritation  from  over- 
stimulation of  the  nasal  branches  of  the  trigeminal  nerve,  when  large 
quantities  of  ether  are  suddenly  poured  upon  the  inhaler  or  the 
strength  of  the  drug  is  too  rapidly  increased.  The  patient  suddenly 
stops  breathing  and  becomes  cyanosed,  but  the  pupillary  reaction 
remains  and  the  pulse  is  usually  good;  and,  if  artificial  respiration  be 
promptly  performed,  the  danger  is  overcome. 

When  the  condition  occurs  in  the  later  stages,  after  deep  narcosis, 
it  is  the  result  of  too  much  anesthetic,  producing  paralysis  of  the 
medullary  centers,  and  is  a  more  dangerous  condition.  The  pupils 
suddenly  dilate  and  fail  to  respond  to  light,  and  the  conjunctival 
reflex  is  lost;  the  respirations  become  progressively  weaker  and  more 
superficial,  and  finally  stop.  The  patient  has  an  ashen-gray  look, 
lies  in  a  state  of  extreme  relaxation,  and  the  heart  ceases  to  beat  after 
a  few  seconds. 

Treatment. — This  is  a  condition  requiring  prompt  and  energetic 
treatment.  The  anesthetic  and  the  operation  should  be  immediately 
stopped  and  every  effort  made  to  revive  the  patient.  It  should  be 
seen  that  there  is  no  impediment  to  the  free  entrance  of  air  into  the 
respiratory  passages,  and  then  the  foot  of  the  table  should  be  elevated 
upon  a  stool,  while  artificial  respiration  is  performed  after  the  manner 
above  described  (page  52). 

Cardiac  Paralysis. — Syncope  may  occur  during  anesthesia  from 
chloroform  or  ether,  but  is  more  apt  to  be  produced  by  the  former. 
It  is  the  most  serious  of  all  the  anesthetic  accidents.  From  the  fact 
that  a  great  proportion  of  the  deaths  from  chloroform  anesthesia 
occur  in  the  early  stages,  when  only  a  small  quantity  of  the  anesthetic 
has  been  given,  it  has  been  contended  that  fright,  producing  vaso- 
motor paralysis,  is  the  cause.  There  is  no  doubt  that  fright  or  strug- 
gling during  the  early  stage  of  anesthesia  is  sufficient  in  some  cases 
to  cause  dilatation  of  the  heart  and  vasomotor  paralysis,  especially 
if  the  individual  is  already  affected  with  degenerative  changes  in  the 
heart,  or  is  suffering  from  severe  anemia  or  shock.     But  fatal  syncope 


has  occurred  in  many  cases  after  only  a  few  inhalations  of  chloroform, 
when  the  patient  was  in  strong  physical  condition  and  exhibited  no 
fear  of  the  operation  whatever.  Such  cases  and  those  occurring  after 
full  anesthesia  has  been  established  can  only  be  ascribed  to  the  toxic 
action  of  the  drug  from  sudden  overdosage. 

When  circulatory  paralysis  occurs,  the  pulse  first  becomes  weak 
and  irregular,  and  then  feeble  and  fluttering;  the  skin  becomes  pal- 
lid, the  pupils  dilate  and  remain  fixed,  and  finally  the  heart  stops 
entirely.  Irregular  attempts  at  breathing  may  continue  for  a  few 
moments  after  cessation  of  the  heart-beat.  Postmortem  examina- 
tion reveals  a  heart  dilated  and  overcharged  with  blood,  and 
general  dilatation  of  the  capillaries  and  veins,  especially  in  the  abdo- 
men, showing  that  the  patient  has  practically  bled  into  his  own 
vessels,  and  nearly  all  the  blood  is  withdrawn  from  the  cerebral 

Treatment. — The  treatment  of  such  a  condition  should  consist 
in  artificial  respiration  and  in  adopting  means  to  overcome  the  cere- 
bral anemia  and  to  empty  the  engorged  heart.  In  the  presence  of 
signs  pointing  to  syncope,  the  treatment  should,  be  instituted 
promptly,  without  waiting  for  cessation  of  respiration.  The  foot 
of  the  table  should  be  immediately  elevated  to  an  angle  of  45  degrees, 
so  that  the  patient  is  in  an  exaggerated  Trendelenburg  position. 
Children  may  be  inverted  by  simply  holding  them  by  the  heels. 
Combined  with  position,  compression  of  the  limbs  and  abdomen  by 
means  of  bandages  may  be  employed  to  force  the  blood  from  the 
dilated  capillaries  and  splanchnic  areas.  Artificial  respiration  and 
oxygen  inhalations  should  be  employed  from  the  start,  as  already 
described.  Massage  of  the  heart  for  the  purpose  of  emptying  it  of 
the  engorged  blood  should  also  be  practised. 

External  cardiac  massage  maybe  readily  carried  out  with  the  hand 
placed  over  the  precordium  by  elevating  and  depressing  the  wrist- 
joint  at  about  the  rate  of  the  normal  beat.  In  abdominal  operations 
the  heart  may  be  massaged  by  grasping  it  between  the  thumb  and 
forefinger,  through  the  relaxed  diaphragm,  and  alternately  compress- 
ing and  relaxing  it  twenty  to  forty  times  a  minute.  Direct  cardiac 
massage  can  be  practised  through  an  incision  in  the  fourth  intercostal 
space  and  opening  the  pericardium.  This  operation  has  been  suc- 
cessfully performed  in  some  seemingly  hopeless  cases,  and  is  worthy 
of  trial. 

Cardiac  stimulants,  such  as  strychnin,  are  of  little  use  until  the 
circulation  is  reestablished;  a  hypodermic  of  some  rapid  acting  drug, 


however,  as  adrenalin  chlorid,  5  to  2oTri  (0.30  to  1.25  c.c.)  injected 
into  a  vein,  camphorated  oil,  2oTn.  (1.25  c.c),  whisky,  2oTri  (1.25 
c.c),  etc.,  may  be  tried  with  better  chances  of  success. '  An  intra- 
venous infusion  of  hot  salt  solution,  combined  with  15  to  3oTn. 
(i  to  2  c.c)  of  a  I  to  1000  solution  of  adrenalin  chlorid  injected 
drop  by  drop  by  means  of  a  hypodermic  directly  into  the  rubber 
tube  of  the  infusion  apparatus  while  the  solution  is  flowing,  should 
be  given  by  an  assistant  while  the  other  means  of  treatment  are  being 
carried  out.  According  to  Crile's  experiments,  an  intraarterial  in- 
fusion of  adrenahn  in  salt  solution  injected  toward  the  heart  (see 
page  145)  has  more  effect  in  raising  blood-pressure  and  would  be  a 
more  rational  form  of  treatment.  When  there  is  no  improvement 
within  ten  or  fifteen  minutes,  the  case  is  usually  hopeless. 


Vomiting. — This  is  the  most  frequent  postanesthetic  complica- 
tion. The  best  way  to  avoid  it  is  by  careful  preparation  of  the 
patient  before  anesthesia  and  a  skilful  administration  of  the  anes- 
thetic. In  some  cases,  however,  it  occurs  in  spite  of  all  that  can  be 
done,  and  may  be  persistent.  That  from  chloroform  is  usually 
more  severe  and  more  difficult  to  treat. 

For  the  ordinary  vomiting,  inhalations  of  vinegar,  ice  in  small 
quantities  by  mouth,  or  very  hot  water  in  small  doses  (teaspoonfuls) 
are  the  common  remedies.  The  latter  is  most  efficient,  serving  to 
dilute  the  mucus  and  wash  out  the  stomach  contents.  Fifteen  to 
20  gr.  (i  to  1.5  gm.)  of  bicarbonate  of  soda  in  a  glass  of  warm  water 
is  also  recommended.  Likewise  pure  olive  oil  in  ounce  doses  has 
been  successfully  employed.  Cerium  oxalate,  gr.  v  (0.3  gm.),  bis- 
muth subnitrate,  gr.  v  (0.3  gm.),  acetanilid  in  i  gr.  (0.065  g^^-) 
doses  every  one-half  hour  until  8  gr.  (0.5  gm.)  have  been  taken, 
morphin,  or  small  doses  [1/12  gr.  (0.0054  gm.)]  of  cocain  every  half 
hour  up  to  I  gr.  (0.065  gm.)  may  be  used  in  the  more  troublesome 
cases.  If  the  condition  becomes  persistent  and  severe,  lavage  of  the 
stomach  (see  page  494)  should  be  carried  out  and  repeated  as  often 
as  necessary.  In  fact,  it  is  the  best  means  of  preventing  vomiting 
in  any  case,  and  some  surgeons  employ  it  as  a  routine,  having  it 
performed  while  the  patient  is  still  on  the  operating-table  before 
becoming  conscious. 

Respiratory  Complications. — These  are  seen  more  frequently 
after  ether  than  chloroform,  and  include  edema  of  the  lungs,  bron- 


chitis,  bronchopneumonia,  and  lobar  pneumonia.  They  should  be 
treated  along  the  lines  ordinarily  followed  in  such  cases.  Lung  com- 
plications are  especially  liable  to  follow  anesthesia  where  a  diseased 
condition  is  already  present,  as  bronchitis,  emphysema,  or  tuber- 
culosis, or  in  the  aged  or  feeble. 

To  avoid  as  far  as  possible  such  complications,  the  mouth,  nose, 
and  teeth  should  be  carefully  cleansed  before  anesthesia,  the  appa- 
ratus employed  for  administering  the  anesthetic  should  not  be  carried 
from  one  patient  to  another  without  sterilization,  and  due  care  should 
be  observed  while  administering  the  anesthetic  to  prevent  aspiration 
of  fluids  or  vomitus.  As  a  further  precautionary  measure,  the  patient 
should  always  be  carefully  protected  against  chilling,  both  during  the 
anesthesia  and  while  he  is  being  removed  to  his  bed. 

Renal  Complications. — Temporary  albuminuria  and  casts  are 
not  uncommon  after  both  ether  and  chloroform,  and,  if  a  diseased 
condition  of  the  kidneys  be  present  beforehand,  it  is  much  aggra- 
vated, though  of  the  two  drugs  chloroform  exerts  less  of  an  irritant 
action.  Scanty  excretion  of  urine  with  actual  suppression  and  hema- 
turia are  occasionally  seen.  Such  a  condition  should  be  treated  by 
mild  diuretics,  cathartics,  and  saline  rectal  irrigations. 

Postoperative  Anesthetic  Paralyses. — These  are  mostly  per- 
ipheral from  pressure  upon  some  nerve  during  the  period  of  uncon- 
sciousness, though  paralysis  of  central  origin  may  take  place  as  the 
result  of  cerebral  emboHsm  or  hemorrhage,  especially  in  those  with 
high  arterial  tension  and  degenerative  changes  in  the  blood-vessels. 
Peripheral  paralysis  may  affect  the  arm,  leg,  or  face.  Injury  to  the 
musculospiral  nerve  from  pressure  by  the  edge  of  the  table  if  the  arm 
is  allowed  to  hang  down,  and  injury  to  the  brachial  plexus  from  pres- 
sure between  the  clavicle  and  first  rib,  or  by  the  head  of  the  humerus 
when  the  arms  are  fastened  above  the  head  are  the  most  frequent 

Delayed  Poisoning. — Certain  of  the  late  deaths  occurring  after 
anesthesia,  that  were  formerly  supposed  to  be  due  to  sepsis,  shock,  fat 
embolism,  etc.,  are  now  known  to  be  due  to  an  acid  intoxication. 
This  condition,  variously  designated  as  cholemia,  acidosis,  aceto- 
nuria,  and  acid  intoxication,  most  frequently  follows  chloroform  nar- 
cosis and  is  more  common  among  children.  The  symptoms  do  not 
appear  until  the  patient  has  recovered  from  the  anesthesia  develop- 
ing in  from  10  to  150  hours  (Bevan  and  Favill). 

The  condition  is  characterized  by  persistent  vomiting,  jaundice, 
sweetish  breath,   rapid  pulse.   Cheyne-Stokes  respiration,  in  some 


cases  extreme  restlessness  and  excitability,  in  others  delirium,  con- 
vulsions, and  coma.  In  some  the  temperature  is  exceedingly  high, 
in  others  it  is  subnormal.  Death  in  fatal  cases  occurs  within  three 
to  five  days.  At  postmortem  there  is  found  a  condition  of  fatty 
degeneration  of  the  kidneys,  heart  muscle,  and  hver,  most  marked 
in  the  latter,  and  at  times  actual  necrosis  of  the  Hver  is  seen.  This 
condition  is  the  result  of  the  destructive  action  of  chloroform  upon  the 
cells.  The  insufficiency  of  the  hver  results  in  the  accumulation  of 
toxins,  and  acetone,  diacetic  acid,  and  oxybutyric  acid  appear  in  the 
blood  and  urine  as  by-products. 

Bicarbonate  of  soda  given  by  mouth  in  mild  cases,  and  in  salt 
solution  by  rectum,  by  hypodermoclysis,  or  intravenously  in  the 
severer  ones,  seems  the  most  valuable  remedy  for  this  condition.  For 
intravenous  injection  i  1/2  ounces  (45  gm.)  of  bicarbonate  of  soda 
is  dissolved  in  i  quart  (liter)  of  normal  salt  solution  [salt  5  ii  (8  gm.) 
to  the  quart  (1000  c.c.)  of  water],  and  1/2  pint  (250  c.c.)  is  admin- 
istered every  three  or  four  hours  until  the  entire  amount  is  injected. 
In  addition,  free  ehmination  by  the  skin  should  be  encouraged,  and 
the  bowels  should  be  kept  freely  open. 


Before  moving  a  patient  from  the  operating-table  to  his  bed,  it 
should  be  seen  that  he  is  well  protected  and  properly  wrapped  in  warm 
dry  blankets.  During  the  process  of  moving,  care  should  be  taken 
not  to  elevate  the  head  or  chest.  The  recovery  room  should  be  well 
ventilated,  but  the  patient  should  be  protected  from  any  draughts. 
The  bed  should  have  been  previously  prepared  and  well  warmed  by 
means  of  hot-water  bags,  which  are  to  be  removed,  however,  when  the 
patient  is  received,  unless  there  is  some  special  indication  for  their 
use,  as  in  shock  or  collapse.  If  used,  hot- water  bags  should  always 
be  covered  with  flannel  and  care  should  be  taken  to  see  that  they  are 
not  hot  enough  to  burn  the  patient. 

The  best  position  for  the  patient  is  flat  upon  the  back,  with  the 
head  level  or  a  little  lower  than  the  body,  and  with  the  face  turned 
to  one  side.  If  vomiting  occurs,  the  patient  should  be  turned 
slightly  to  one  side  and  the  vomitus  received  in  a  basin,  after  which 
the  mouth  should  be  wiped  out.  Frequent  rinsing  of  the  mouth 
with  warm  water  may  be  practised  if  the  patient  is  conscious,  and 
will  be  found  to  be  very  grateful.     The  patient  should  be  watched 



by  an  attendant  until  consciousness  returns,  for,  if  left  alone,  he  may- 
choke  from  mucus  or  vomited  material  collecting  in  the  throat,  or 
attempt  to  sit  up,  remove  his  dressings,  or  in  other  ways  do  himself 
harm.  Delirious  patients  should  be  gently  restrained,  but  not  tied 
in  bed.  Inhalations  of  oxygen  or  vinegar,  and  washing  the  patient's 
face  in  cold  water,  are  of  aid  in  arousing  to  consciousness. 

The  patient  should  not  be  allowed  to  sit  up  for  at  least  six  hours. 
Small  quantities  of  hot  water  or  cracked  ice  are  given  in  the  first 
few  hours,  but  no  food  is  allowed  within  six  hours,  and  not  then 

Fig.  39.  —  The  ether  bed. 

unless  the  patient  has  stopped  vomiting.  In  cases  of  collapse,  or 
for  patients  who  are  very  weak,  nutrient  or  stimulating  enemata 
may  be  prescribed  to  sustain  the  patient  until  food  can  be 
taken.  The  first  food  taken  by  mouth  should  be  liquid  in  character, 
consisting  of  broth,  beef  tea,  or  soup.  If  this  is  retained,  other 
articles  of  soft  diet  should  be  added,  until  the  ordinary  diet  is  being 
taken.  It  is  important  to  have  the  urine  examined  for  several  days 
after  anesthesia,  and  after  the  use  of  chloroform  special  reference 
should  be  paid  to  detecting  the  presence  of  acetone  or  diacetic  acid. 


By  local  anesthesia  is  understood  the  abolition  of  pain  sensation 
in  a  chosen  region,  without  the  production  of  unconsciousness. 
Analgesia  is  a  more  correct  term  to  apply  to  this  variety  of  anesthesia, 
but  usage  has  so  perpetuated  the  term  "local  anesthesia"  that  it  will 
be  employed  in  these  pages. 

The  introduction  of  cocain  by  Koller,  in  1884,  first  made  possible 
local  anesthesia  as  it  is  employed  at  the  present  time,  compression  of 
the  nerve  trunks  supplying  the  field  of  operation  by  means  of  a 
tourniquet,  and  the  application  of  cold  to  the  part,  being  the  methods 
most  frequently  resorted  to  previously.  A  further  impetus  was 
given  to  the  development  of  local  anesthesia  by  the  discovery  that 
infiltration  with  cocain,  or  similar  anesthetic  agents,  into  or  around  a 
nerve  trunk  in  any  part  of  its  course  effectually  blocked  the  sensa- 
tion in  the  region  supplied  by  that  particular  nerve  peripheral  to  the 
point  of  injection.  The  introduction  by  Schleich  of  the  method  of 
infiltrating  the  tissues  with  weak  anesthetic  solutions  was  another 
important  step  and  one  that  made  possible  the  safe  employment  of 
cocain  in  really  extensive  operations. 

Through  improvement  in  the  technic  of  the  methods  of  infiltra- 
tion and  nerve  blocking  much  progress  has  been  made  in  the  last  few 
years  in  enlarging  the  field  of  local  anesthesia  until  it  can  now  be 
employed  with  entire  success  in  a  large  number  of  major  operations, 
as  weU  as  the  usual  minor  ones.  Indeed,  it  is  safe  to  say  that  fully 
half  the  operations  performed  at  the  present  time  under  general 
narcosis  could  be  as  satisfactorily  carried  out  under  local  methods 
intelHgently  used. 

In  the  choice  between  local  and  general  anesthesia  for  any  given 
case,  the  question  to  be  decided  is  whether  under  local  anesthesia 
pain  sensibility  can  be  entirely  aboHshed  and,  at  the  same  time, 
sufficient  muscular  relaxation  be  obtained  to  insure  the  proper  per- 
formance of  the  procedures  contemplated.  If  these  condidons  can 
be  satisfactorily  obtained,  and  if  the  operator  possess  the  necessary 
experience  and  skill  in  its  use,  then  local  anesthesia  should  be  offered 



to  the  patient,  if  for  no  other  reason,  simply  to  avoid  the  well-known 
unpleasant  after-effects  of  general  narcosis,  and  to  obtain  a  less  dis- 
turbed and  more  rapid  recovery,  regardless  of  whether  the  particular 
operation  be  classified  as  a  major  or  a  minor  one. 

Advantages  and  Disadvantages  of  Local  Anesthesia. — There  are 
certain  advantages  peculiar  to  local  anesthesia  that  should  be  care- 
fully considered  when  selecting  the  anesthetic  in  any  given  case. 
Most  important  is  the  absolute  safety  to  the  Ufe  of  the  patient  when 
this  form  of  anesthesia  is  employed  with  proper  precautions.  With 
the  substitution  of  the  weak  for  the  old-time  strong  cocain  solutions, 
and  the  discovery  of  the  newer  less  toxic  analgesics,  together  with  a 
knowledge  of  the  amount  of  these  drugs  that  can  be  safely  used,  the 
dangers  of  poisoning  may  be  disregarded. 

Furthermore,  under  local  anesthesia,  shock  is  lessened,  and  the 
depression  observed  after  the  use  of  general  narcosis  is  absent  to  a 
marked  degree,  so  that  this  form  of  anesthesia  becomes  the  method 
of  choice  when  an  anesthetic  is  required  for  those  in  collapse  or  with 
lowered  vitality.  This  is  especially  true  when  the  nerve-blocking 
method  is  employed,  for  it  is  well  known  that  cocain  injected  into  a 
nerve  effectually  blocks  the  passage  of  all  shock-producing  impulses 
along  that  particular  nerve.  As  Crile  puts  it:  "As  no  impulses  of 
any  kind  can  pass  either  upward  or  downward,  there  is  no  more 
shock  in  dividing  the  tissues,  even  the  nerve  trunks  thus  "blocked," 
than  in  dividing  the  sleeve  of  the  patient's  coat."  The  value  of  this 
principle  is  so  well  established  that  the  injection  of  cocain  into  nerve 
trunks  supplying  a  region  of  operation  is  frequently  performed 
for  the  purpose  of  preventing  shock  even  where  general  anesthesia  is 
employed,  as,  for  example,  the  preliminary  blocking  of  the  sciatic 
nerve  in  hip  amputations. 

Under  local  anesthesia  the  postoperative  blood  changes  and  the 
kidney,  heart,  and  lung  complications  are  all  avoided,  while  the 
unpleasant  after-effects  that  pertain  to  general  anesthesia  are  re- 
duced to  a  mimimum.  The  avoidance  of  vomiting  is  especially  im- 
portant for  the  proper  healing  of  wounds,  and  the  prevention  of 
such  complications  as  hernia.  A  further  advantage  in  operat- 
ing under  local  methods  is  that  the  most  favorable  conditions 
for  primary  union  are  obtained,  for,  as  gentleness  in  handling  tissues 
is  essential  for  the  successful  employment  of  this  method  of  anes- 
thesia, the  minimum  amount  of  trauma  will  be  inflicted  upon  the 

Another  feature  connected  with  an  operation  under  local  anes- 


thesia  is  that  it  does  away  with  the  necessity  for  an  anesthetist,  and 
often  of  any  kind  of  an  assistant — a  very  important  consideration 
under  some  circumstances. 

In  certain  operations — hernia,  for  example — there  is  a  distinct 
advantage  in  having  the  patient  conscious,  that  he  may  demonstrate 
the  protrusion  by  coughing.  On  the  other  hand,  in  some  cases 
consciousness  and  the  knowledge  of  what  is  going  on  is  of  distinct 
disadvantage,  and  in  nervous  or  hysterical  individuals  it  may  become 
a  contraindication,  depending  upon  the  control  the  operator  has  over 
his  patient. 

There  is  no  doubt  that  it  requires  more  time  to  operate  under 
local  than  under  general  anesthesia,  and  that  it  necessitates  the  pos- 
session of  patience  and  tact  upon  the  part  of  the  operator.  As 
Matas  obser\^es,  ''it  is  this  tax  upon  the  operator's  attention,  and  the 
vigilance  required  to  keep  the  inhibitory  powers  of  the  patient  under 
control,  and  the  time  consumed  in  the  anesthetizing  procedure  that 
will  prevent  cocain  and  the  local  analgesics  from  gaining  ascendency 
in  the  crowded  amphitheaters  of  popular  teachers  where  quick  and 
brilliant  work  is  expected  by  an  impatient  audience."  This  incon- 
venience to  which  the  operator  is  subjected,  coupled  with  the  general 
uniamiliarity  with  the  proper  technic,  probably  accounts  for  the  fact 
that  the  -wide  scope  of  local  anesthesia  is  not  more  generally  taken 
advantage  of  at  the  present  time. 

Suitable  Cases. — Besides  the  minor  surgical  procedures,  such  as 
the  incision  of  an  abscess,  exploratory  puncture,  removing  small 
cysts,  amputating  toes  or  fingers,  performing  circumcisions,  etc., 
major  operations  of  any  magnitude  and  extent  may  be  performed, 
provided  the  region  is  capable  of  being  anesthetized  by  infiltration 
or  nerve  blocking. 

For  the  removal  of  practically  ail  benign  growths  such  as  lipo- 
mata,  wens,  cysts,  benign  tumors  of  the  breast,  and  for  the  removal  of 
superficial  isolated  glands,  local  anesthesia  is  quite  sufficient. 
Whether  tuberculous  glands  of  the  neck  should  be  attempted  under 
local  anesthesia  will  depend  upon  their  extent.  If  we  can  be  sure 
there  are  but  one  or  two  superficial  glands,  it  may  be  readily  done, 
but  in  the  writer's  opinion  it  is  rarely  possible  to  define  the  extent  of 
these  operations  beforehand,  and  it  is  not  an  uncommon  experience 
in  apparently  simple  cases  Avhen  the  field  of  operation  is  thoroughly 
exposed  to  find  a  chain  of  matted  glands  requiring  deep  and  wide 
dissection  for  their  removal.  For  the  same  reasons,  and  because  the 
limits  of  the  disease  are  not  well  defined  when  the  tissues  are  swollen 


by  the  infiltrated  fluid  local  anesthesia  is  not  as  a  rule  suitable  for 
the  removal  of  malignant  growths. 

Amputations  of  any  of  the  limbs  may  be  performed  if  the  large 
sensory  nerves  are  properly  blocked.  By  means  of  a  preliminary  co- 
cainization  of  the  sciatic  and  anterior  crural  nerves,  amputation  of 
the  leg  has  been  often  painlessly  performed  when  a  general  anesthetic 
was  contraindicated.  The  same  principle  applies  to  amputations  of 
other  limbs. 

]\Iany  of  the  operations  upon  the  superficial  bones,  such  as  wiring 
and  plating  fractures  and  rib  resections,  may  be  painlessly  performed 
if  the  periosteum  as  well  as  the  more  superficial  tissues  are  rendered 
insensible  by  proper  infiltration.  Thus  fractures  of  the  lower  jaw, 
the  clavicle,  the  olecranon,  and  the  patella  can  readily  be  operated 
upon  by  local  methods.  The  latter  operation  lends  itself  especially 
to  local  anesthesia  on  account  of  the  superficial  position  of  the  bone 
and  the  scarcity  of  sensory  nerves  in  that  region. 

For  the  majority  of  abdominal  operations  local  anesthesia  is  not 
satisfactory.  It  is  not  that  there  is  any  difficulty  in  entering  the 
abdominal  cavity — this  can  be  very  readily  done  under  careful  in- 
filtration of  the  various  layers  of  the  abdominal  wall — but  the  trouble 
is  in  meeting  the  various  comphcations  that  may  be  present.  We 
know  that  the  abdominal  organs  are  insensible  to  pain,  but  the 
parietal  peritoneum  is  most  sensitive,  especially  if  inflamed.  The 
separation  of  adhesions  and  procedures  that  require  dragging  upon 
the  mesentery  are  likewise  painful.  Exploratory  operations  and  pro- 
cedures, such  as  colostomy,  gastrostomy,  gastrotomy,  simple  drain- 
age of  the  gall-bladder  and  appendiceal  abscess,  suprapubic  cystotomy, 
suture  of  the  intestines  following  typhoid  perforation,  appendicostomy , 
and  some  interval  operations  for  appendicitis,  requiring  but  little 
intraabdominal  manipulation,  can  be  readily  performed  without  a 
general  anesthetic;  but  when  extensive  manipulation  is  required, 
with  the  separation  of  adhesions  necessitating  more  or  less  pulhng 
upon  the  mesentery,  local  anesthesia  is  contraindicated.  Further- 
more, in  abdominal  surgery  complete  muscular  relaxation  is  usually 
required  to  secure  the  necessary  wide  retraction,  and  this  cannot 
always  be  obtained  under  local  anesthesia. 

Local  anesthesia  is  ideal  in  the  operations  for  inguinal  hernia  on 
account  of  the  superficial  location  of  the  structures  involved  and  the 
definite  position  and  course  of  the  sensory  nerve  trunks  supplying  the 
region  of  operation.  Other  forms  of  hernia  may  be  operated  upon 
by  employing  infiltration  alone,  but  not  with  the  entire  satisfaction 


obtained  in  the  inguinal  variety.  For  strangulated  hernia  of  any 
variety,  local  anesthesia  should  always  be  the  choice.  The  addi- 
tional strain  of  general  anesthesia  upon  these  patients,  already  toxic, 
frequently  produces  more  depression  than  they  can  withstand,  and, 
as  there  is  no  need  for  haste,  abundance  of  time  may  be  taken  in 
attempts  at  restoration  of  gut  of  doubtful  vitality,  without  adding 
a  particle  to  the  shock  of  the  operation. 

Tracheotomy,  thyroidectomy,  the  ligation  of  blood-vessels,  the 
repair  of  the  perineum  and  cervix,  and  any  of  the  operations 
about  the  scrotum,  as  those  for  castration,  varicocele,  or  hydrocele, 
are  all  amenable  to  local  anesthesia.  Quite  extensive  operations 
about  the  rectum  have  been  performed  by  some  operators  under 
local  anesthesia,  but  for  most  of  the  work  in  this  region  thorough 
stretching  of  the  sphincter  ani  is  essential,  and  this  cannot  be  per- 
formed painlessly  by  this  method;  for  this  reason  it  is  unsuitable  in 
the  majority  of  cases.  However,  simple  operative  procedures,  such 
as  those  for  fissure,  external  and  thrombotic  hemorrhoids,  and  straight 
uncomplicated  fistulae  are  within  the  scope  of  local  anesthesia. 

By  a  skilful  use  of  local  anesthesia  in  the  hands  of  one  thoroughly 
familiar  with  the  technic  of  infiltration  and  nerve  blocking,  this  list 
may  be  considerably  enlarged.  Furthermore,  it  should  not  be 
forgotten  that  in  many  operations  too  painful  for  local  anesthesia 
alone,  the  major  portion  of  the  operation  may  be  performed  under 
local  methods,  and  then  nitrous  oxid  gas  or  a  small  quantity  of  ether 
may  be  administered  to  tide  the  patient  over  the  more  painful  pro- 
cedures, thus  avoiding  a  prolonged  general  narcosis. 

Those  cases  in  which  local  anesthesia  is  impracticable  have  been 
already  indicated  in  a  general  way.  In  addition,  for  young  children, 
for  those  who  are  greatly  excited  or  hysterical,  and  for  insane  or 
delirious  individuals,  local  anesthesia  is  generally  contraindicated, 
or  at  best  it  is  very  unsatisfactory  on  account  of  the  difficulty  of 
obtaining  the  necessary  quietude. 

Methods  of  Producing  Local  Anesthesia. — At  the  present  time 
two  methods  of  producing  local  anesthesia  are  recognized:  (i)  The 
use  of  agents  which  freeze  the  tissues,  and  (2)  the  use  of  chemical 
anesthetics  or  analgesics,  of  which  cocain  is  a  type.  Freezing  of  the 
tissues  has  a  very  limited  field  of  usefulness — practically  none  in 
major  surgery — and  it  is  upon  some  of  the  analgesic  agents  that  we 
have  to  rely  largely. 

The  methods  of  employing  anesthetics  may  be  in  turn  divided 
into  two  classes:     (i)  Where  the  drug  is  used  in  such  a  way  that  the 


endings  of  the  sensory  nerves  are  paralyzed  (terminal  anesthesia) ;  and 
(2)  where  the  drug  is  brought  in  contact  with  a  nerve  trunk  in  some 
part  of  its  course,  thereby  blocking  the  sensory  conductivity  of  that 
particular  nerve  and  rendering  the  area  supplied  by  it  devoid  of 
sensation  (regional  anesthesia).  To  the  first  class  belong  the  topical 
application  of  analgesic  drugs  to  mucous  membranes,  and  their 
injection  into  the  tissues  (infiltration  anesthesia),  though  by  this 
latter  method  a  mixture  of  terminal  and  regional  anesthesia  is  often 
produced;  while  regional  anesthesia  may  be  produced  by  the  injec- 
tion of  analgesics  into  a  nerve  trunk  (endoneural  infiltration),  about 
a  nerve  trunk  (perineural  infiltration),  into  the  subarachnoid  space 
(spinal  anesthesia),  or  into  the  extradural  space.  Another  method 
of  producing  local  anesthesia,  termed  venous  anesthesia,  has  lately 
been  introduced  by  Bier,  whereby  the  analgesic  agent  is  injected 
into  the  venous  system  and  is  thus  brought  in  contact  with  the  nerve 
trunks  and  nerve  endings.  This  method  of  anesthesia  is  a  combina- 
tion of  terminal  and  regional  anesthesia. 

Drugs  Employed  for  Local  Anesthesia. — Cocain. — Of  the  many 
local  anesthetics  cocain  was  the  first  employed  and  holds  the  most 
important  place,  having  successfully  stood  the  test  of  time.  When 
applied  to  the  unbroken  skin  it  is  without  effect,  but  in  contact  with 
mucous  membranes  it  completely  deadens  sensibility  within  a  few 
moments.  Injected  into  the  tissues,  cocain  produces  anesthesia 
within  the  area  of  contact;  when  injected  into  or  about  a  sensory 
nerve,  it  is  rapidly  absorbed  and  produces  complete  insensibility  in  the 
whole  distribution  of  the  nerve  peripheral  to  the  point  of  injection. 

Solutions  of  cocain  should  always  be  freshly  prepared  at  the  time  of 
operation,  as  it  is  well  known  that  they  are  prone  to  decompose,  and 
in  a  short  time  such  a  solution  becomes  capable  of  producing  sup- 
puration. A  medium  isotonic  with  the  fluids  of  the  body,  as  normal 
salt  solution,  is  the  best  for  dissolving  the  cocain.  Such  a  solution, 
producing  neither  swelling  of  the  tissues,  as  water  does,  nor  shrinkage 
of  the  cells,  as  is  the  case  with  the  more  concentrated  saline  solutions, 
has  no  injurious  effects  upon  the  tissues.  The  effectiveness  of  the 
solution  is  also  increased  by  using  it  warm. 

As  solutions  of  cocain  will  not  stand  prolonged  boiling,  the  salt  or 
tablet  should  be  previously  sterilized  by  dry  heat.  An  efficient 
method  is  to  place  the  cocain  in  a  small  test-tube  plugged  with  cotton, 
and  then  to  sterilize  it  by  means  of  dry  heat  at  a  temperature  of  300° 
F.  for  fifteen  minutes.     Several  firms^  prepare  hermetically  sealed 

'  Parke,  Davis  &  Co.,  and  Squibbs. 



glass  tubes  of  sterilized  salt  and  cocain  according  to  Bodine's  formula, 
each  tube  containing  2  4/5  gr.  (0.18  gm.)  of  sodium  chlorid  and  i 
gr.  (0.065  gm.)  of  cocain  muriate.  The  contents  of  one  of  these  tubes 
dissolved  in  an  ounce  (30  c.c.)  of  sterile  water  gives  approximately  a 
I  to  500  solution  of  cocain  in  normal  salt  solution.  Alkalis  render 
cocain  inert.  For  this  reason  soda  should  not  be  put  in  the  water  in 
which  the  syringes,  needles,  and  solution  glasses  are  boiled. 

Solutions  of  cocain  used  in  the  following  strength  will  be  found 
amply  strong  for  the  purpose  for  which  they  are  recommended.  For 
anesthetizing  the  skin  and  for  perineural  injections,  a  i  to  500  (1/5 
of  I  per  cent.)  solution;  for  deeper  infiltration,  a  i  to  1000  (i/io  of 

1  per  cent.)  solution;  for  massive  infiltration,  a  i  to  3000  (1/30  of  i 
per  cent.)  solution;  and  for  endoneural  injections,  10  to  30111  (0.6  to 

2  c.c.)  of  a  I  to  200  (1/2  of  I  per  cent.)  solution  are  employed. 
Schleich  has  three  solutions  containing  a  combination  of  cocain, 
morphin,  and  sodium  chlorid: 

No.  I,  strong 

No.  2,  medium 

No.  3,  weak 

Cocain  hydrochlor- 

gr.  3     (0.2     gm.)      gr.  i  1/2  (c.i  gm.) 

gr.  1/6  (o.oi  gm.) 


Morphin       hydro- 

gr.  1/3    (0.02  gm.)    gr.  1/3  (0.02  gm.)|  gr.  1/12  (0.005 



Chlorid  of  sodium 

gr.  3   (0.2  gm.)        i  gr.  3  (0.2  gm.) 

gr.  3  (c.2  gm.) 

Distilled  sterilized 

oz.  3  1/3  (100  c.c.)  oz.  3  1/3  (100  c.c.) 

oz.  3  1/3  (100  c.c.) 


The  strong  solution  is  used  for  the  skin,  perineural  injections, 
etc.  An  ounce  (30  c.c.)  may  be  used  without  risk.  Of  the  medium 
strength  solution,  used  for  ordinary  infiltration  of  the  tissues  below 
the  skin,  2  ounces  (60  c.c.)  may  be  used;  while  as  much  as  10 
ounces  (300  c.c.)  of  the  weaker  solution,  which  is  employed  for 
massive  infiltration  of  large  areas,  may  be  safely  injected.  Tablets 
according  to  the  Schleich  formulae  may  be  obtained  from  most  phar- 
macists, with  full  directions  for  the  preparation  of  a  solution  of  any 
given  strength.  Schleich's  solutions  find  favor  with  many  operators, 
but  personally  the  writer  prefers  to  administer  the  morphin  separately 
•in  a  definite  dose  by  hypodermic  half  an  hour  before  operation. 

The  addition  of  adrenalin  chlorid  to  the  cocain  solution,  as 
advocated  by  Braun,  is  of  distinct  advantage.     Adrenalin  is  a  vaso- 


constrictor  and  has  the  same  effect  in  the  way  of  an  adjunct  to  local 
anesthesia  as  constriction  of  the  part  has,  increasing  as  well  as  pro- 
longing the  anesthetic  effects  to  a  marked  degree.  At  the  same  time, 
by  preventing  capillary  oozing,  it  gives  a  much  drier  lield  of  opera- 
tion. With  its  use  there  is  some  danger  of  secondary  hemorrhage 
if  the  large  blood-vessels  are  not  properly  secured,  since,  owing  to  its 
styptic  action,  even  arteries  of  some  size  may  be  prevented  from 
bleeding  at  the  time  and  so  be  overlooked.  It  is  a  good  rule,  there- 
fore, to  at  least  clamp  any  vessel  that  bleeds,  however  slightly,  when 
using  adrenahn.  From  5  to  10  minims  (0.3  to  0.6  c.c.)  of  the  i 
to  1000  solution  of  adrenalin  chlorid  is  added  to  the  cocain  and  salt 
solution  before  it  is  to  be  used. 

In  the  early  history  of  its  development  cocain  was  used  in  solu- 
tions as  strong  as  10  and  15  per  cent.,  with  the  result  that  frequently 
a  set  of  dangerous  symptoms,  and  in  some  cases  death,  were  the 
sequels.  This  toxic  action  is  due  to  the  absorption  of  more  of  the 
drug  than  the  tissues  can  take  care  of.  The  amount  of  the  drug  that 
can  be  injected  into  the  tissues  with  safety  depends  upon  the  strength 
of  the  solution  as  well  as  the  method  of  injection.  To  be  well  within 
the  limits  of  safety,  not  more  than  3/4  gr.  (0.0486  gm.)  of  cocain 
should  be  allowed  to  remain  unconfined  in  the  tissues,  nor  should 
this  amount  be  exceeded  when  applied  to  mucous  membranes  from 
which  rapid  absorption  takes  place.  With  the  weaker  cocain  solu- 
tions (0.2  to  0.1  per  cent.)  it  is  rarely  necessary  to  exceed  this  amount, 
even  in  extensive  operations.  Of  course,  when  a  large  proportion  of 
the  solution  escapes,  or  when  the  circulation  is  impeded  by  constric- 
tion, a  larger  amount  may  be  used  with  safety. 

To  avoid  the  untoward  effects  of  cocain,  a  number  of  drugs,  as 
eucain  B,  tropacocain,  stovain,  alypin,  novocain,  acoin,  nirvanin, 
orthoform,  anesthesin.  quinin  and  urea  hydrochlorid,  etc.,  which  are 
less  toxic  but  have  about  the  same  action  as  cocain,  have  been  intro- 
duced as  substitutes.  Of  these,  eucain  B,  novocain,  and  quinin  and 
urea  are  probably  most  frequently  used.  These  newer  preparations 
are  preferred  by  many  operators  to  cocain,  and  they  have  the  advan- 
tage that  their  solutions  may  be  sterilized  by  boiling.  Weak  solu- 
tions of  cocain,  however,  used  with  proper  precautions,  the  writer 
has  always  found  to  be  perfectly  safe  as  well  as  efficient. 

B-Eucain. — Eucain  was  one  of  the  first  substitutes  for  cocain. 
It  is  claimed  to  be  one-fourth  as  toxic  as  cocain;  on  the  other  hand  the 
anesthetic  effect  is  slower  and  less  pronounced.  It  has  the  advan- 
tage over  cocain  that  its  solutions  may  be  boiled.     Eucain  is  a  vaso- 



dilator  and  the  addition  of  adrenalin  to  its  solutions  has  not  nearly 
so  pronounced  an  effect  as  when  added  to  cocain.  The  drug  is 
generally  used  in  1/2  per  cent,  solution  with  adrenalin. 

Novocain. — Novocain,  one  of  the  more  recent  and  at  the  present 
time  the  most  popular  substitute  for  cocain,  was  introduced  in  1905. 
It  is  estimated  to  be  one-sixth  to  one-seventh  as  toxic  as  cocain.  Like 
eucain,  its  solutions  are  not  affected  by  boiling.  It  is  precipitated 
from  solution  by  free  or  carbonated  alkalis,  so  syringes,  needles,  etc., 
should  be  boiled  in  pure  water.  Used  in  conjunction  with  adrenalin 
its  anesthetic  powers  are  about  equal  to  cocain  when  injected  into  the 
tissues,  but  as  a  local  anesthetic  for  mucous  surfaces  it  is  far  inferior 
to  cocain. 

Braun  employs  four  novocain  solutions: 

No.  I 

No.  II 

No.  Ill 

No.  IV 

Novocain..  . 

3  3/4  gr.    (0.2s  gm.) 

3  3/4  gr.    (0.25   gm.) 

I  1/2  gr.    (o.i    gm.) 

I  1/2    gr.  (o.i    gm.) 

Normal    salt 


3  1/3  oz.  (100  c.c.)      I  2/3  oz.  (50  c.c.) 

2  1/2  dr.  (10  c.c.) 

I  1/4  dr.  (5  c.c.) 


i-iooo  or  I 


5  drops 

5  drops 

5  drops 

ID  drops 

4  per  cent.  J 

No.  IV  is  employed  only  for  injecting  large  thick  nerves. 

Quinin  and  Urea  Hydrochlorid. — This  combination  was  intro- 
duced into  surgery  in  1907.  So  far  as  known,  it  has  no  toxic  effects, 
and  the  anesthesia  produced  by  it  is  a  protracted  one,  often  lasting 
four  or  five  days.  In  its  early  use  solutio  ns  of  i  per  cent,  were  employed, 
but  it  was  found  they  produced  an  exudate  of  fibrin  that  sometimes 
interfered  with  wound  healing,  so  that  at  the  present  time  the 
drug  is  employed  in  1/2  to  1/4  per  cent,  solutions.  Upon  mucous 
membranes,  solutions  of  10  to  20  per  cent,  may  be  used.  It,  how- 
ever, does  not  produce  a  shrinkage  of  the  tissues  as  cocain  does 
and  for   this  reason  is  inferior  to  it  in  nasal  work. 

Preparation  of  the  Patient. — The  usual  preparation  of  the  bowels, 
etc.,  recommended  as  preliminary  to  general  anesthesia,  is  advisable. 
There  is  no  need  for  the  patient  to  fast,  however,  and  a  light  meal  of 
eggs,  coffee,  milk,  toast,  etc.,  may  be  allowed,  unless  the  character 
of  the  operation  contraindicates  it.  If  it  seems  probable  that  a 
general  anesthetic  will  be  required  to  complete  the  operation,  the 
patient's  stomach  should,  of  course,  be  empty,  and  the  same  precau- 
tions should  be  taken  as  for  general  anesthesia  (see  page  2).     Appre- 


hensive  anticipation  on  the  part  of  the  patient  should  be  prevented 
as  far  as  possible  by  reassurances  and  by  a  good  night's  sleep  before 
the  operation. 

Preliminary  medication  with  morphin  is  advisable  in  all  cases, 
where  the  operation  is  to  be  at  all  extensive,  unless  some  distinct 
contraindication  to  its  use  exists.  It  serves  a  threefold  purpose:  it 
allays  nervousness  on  the  part  of  the  patient  and  thus  removes  the 
psychic  element;  it  somewhat  deadens  sensibility;  and  it  is  the 
physiological  antidote  for  cocain  poisoning.  It  may  be  given  hy- 
podermically  in  the  dose  of  i/6  to  1/4  gr.  (0.0108  to  0.0162  gm.)  a 
half  hour  before  operation.  In  some  cases,  where  the  patient  is 
especially  nervous  or  unusual  difficulties  are  expected,  morphin 
1/4  gr.  (0.0162  gm.)  combined  with  i/ioo  gr.  (0.00065  gm.)  of 
hyoscin  may  be  administered  hypodermically  two  hours  before 

The  Conduction  of  the  Operation. — It  may  not  be  out  of  place  at 
this  point  to  say  a  few  words  about  the  proper  conduction  of  an  opera- 
tion under  local  anesthesia.  The  successful  and  satisfactory  em- 
ployment of  this  method  of  anesthesia  depends  upon  an  intelligent 
appreciation  of  its  limitations,  upon  the  experience  and  skill  of  the 
operator,  and  upon  an  accurate  knowledge  of  the  sensory  nerve  supply 
in  an}'  given  region.  These  are  essential.  Much  also  depends  upon 
the  temperament  of  the  operator  and  upon  his  method  of  operating. 
For  this  reason,  with  some  operators,  the  use  of  local  anesthesia  will 
be  impossible;  with  others,  it  will  necessitate  a  radical  change  in  their 
operative  technic.  A  nervous  fidgety  operator,  in  a  hurry  to  get 
through  his  work,  will  never  find  much  to  encourage  him  in  attempts 
to  employ  local  anesthesia  in  major  surgery. 

It  is  important,  in  the  first  place,  to  make  the  patient  as  comfort- 
able as  possible  upon  the  operating-table.  Operations  under  local 
anesthesia  consume  considerable  time,  and  it  is  a  hardship  to  keep  a 
conscious  patient  upon  the  ordinary  hard-topped  operating-table  for 
an  hour  or  more.  Several  thicknesses  of  blanket,  an  air  mattress,  or 
a  layer  of  soft  pillows  placed  upon  the  table,  will  add  much  to  the 
patient's  comfort,  as  well  as  to  the  peace  of  mind  of  the  operator. 
The  patient  should  always  be  recumbent,  and  a  comfortable,  relaxed 
attitude  should  be  assumed,  with  the  arms  folded  over  the  chest  or 
clasped  above  the  head.  While  washing  the  patient  in  preparation 
for  the  operation,  it  should  be  borne  in  mind  that  he  is  conscious 
and  great  gentleness  should  be  employed  in  the  process.  Care 
should  also  be  taken  not  to  soak  the  patient  with  large  quantities  of 


solution  and  leave  him  lying  in  a  chilly  pool  for  the  remainder  of  the 

With  very  nervous  individuals,  it  is  \yell  to  keep  the  instruments 
covered  from  view  and  to  avoid  all  reference  to  knives,  scissors,  etc. 
In  fact,  strict  silence  should  be  enjoined  upon  all.  The  patient's 
mental  attitude  can  be  further  influenced  to  advantage  by  observing 
a  quiet  demeanor  in  the  operating-room,  by  the  avoidance  of  haste, 
and  by  a  most  careful  handling  of  the  tissues.  Clean-cut  dissection 
only  is  allowable  in  operations  under  local  anesthesia.  Rough  ma- 
nipulations, or  tearing  of  the  tissues,  or  unnecessary  pulling  with 
retractors  by  an  awkward  assistant  causes  pain  by  dragging  upon 
structures  outside  the  anesthetized  area  and  is  often  sufficient  to  cause 
restlessness  and  apprehension  on  the  part  of  the  patient,  a  state  of 
mind  which,  if  produced  in  the  early  part  of  an  operation,  rapidly 
changes  to  complete  demoralization,  and  renders  the  chances  of  com- 
pleting the  operation  without  the  aid  of  a  general  anesthetic  very 
smaU.  Rough  wiping  of  the  wound  is  likewise  to  be  avoided.  In 
fact,  in  every  move  and  step  the  aim  of  the  operator  should  be  extreme 
gentleness.  Xeglect  in  observing  these  small  and  apparently  trivial 
details  is  responsible  for  many  of  the  failures  with  local  anesthesia, 
and  often  results  in  condemnation  of  the  method,  though  the  fault 
lies  with  the  operator. 


The  anesthetic  properties  of  intense  cold  have  long  been  recog- 
nized and  utilized  in  minor  surgery.  The  tissues  may  readily  be 
frozen  sufficiently  for  anesthetic  purposes  by  the  apphcation  of  sait- 
and  ice,  or  by  spraying  the  part  with 
some  rapidly  evaporating  chemical. 
such    as    ether,    rhigoline.    or   ethyl 

chlorid.     The  tissues  as  a  result  be-      ^ 

r      ,  1  ]     ,1  11         1      J        Fig.  40. — Ethvl  chlorid  spray  tube, 

come  first  red  and    then    blanched, 

and  a  superficial  anesthesia  is  produced,  which  persists  but  a  few 
minutes.  This  form  of  anesthesia  has  a  very  small  field  of  useful- 
ness, and  is  only  suitable  for  small  incisions  or  punctures;  even  in 
these  cases  the  method  is  open  to  the  objection  that  the  tissues  be- 
come so  hard  that  it  is  diflicult  to  cut  through  them  at  times,  and 
any  dissection  is  out  of  the  question.  Furthermore,  the  thawing 
out  process  is  attended  with  more  or  less  pain.  Freezing  often  lowers 
the  vitality  of  the  tissues  to  such  an  extent  that  sloughing  results; 


especially  is  this  so  when  applied  to  the  tissues  of  poorly  nourished 

Ethyl  chlorid  is  now  used  almost  exclusively  for  the  purpose  of 
freezing,  and  is  both  quick  and  effective.  It  is  obtained  in  glass  tubes 
with  one  end  drawn  out  to  a  line  point  and  furnished  with  a  spring 
tip  (Fig.  40)  or  with  a  screw  cap.  The  method  of  application  is 
extremely  simple.  The  tube  is  uncovered  and  held  inverted  in  the 
hand  at  a  distance  of  12  to  18  inches  (30  to  45  cm.)  from  the  surface  of 
the  skin.  Under  the  heating  influence  of  the  hand  the  liquid  is 
forced  out  of  the  container  upon  the  tissue  in  a  fine  jet  or  spray. 
Rapid  evaporation  occurs,  and,  in  about  thirty  seconds,  the  skin 
becomes  white  and  sufficiently  frozen  to  be  devoid  of  sensation. 


Cocain  and  other  drugs  with  similar  anesthetic  action  may  be 
applied  to  mucous  surfaces  (i)  by  instillation,  as  in  the  eyes,  bladder, 
urethra,  etc.;  (2)  by  means  of  a  spray  or  atomizer,  as  in  the  mouth  or 
nose;  and  (3)  upon  swabs  or  compresses,  either  in  solution  or  in 
crystals.  Only  the  surface  of  the  mucous  membranes  is  anesthetized 
in  this  way,  but  a  number  of  operations  not  involving  the  deeper 
tissues,  such  as  the  removal  of  pol}-pi  or  small  tumors,  and  opening 
of  infections  may  thus  be  performed. 

For  operations  about  the  eye.  a  drop  or  two  of  a  2  to  4  per  cent, 
solution  of  cocain  is  instilled  into  the  eye  every  ten  minutes  until 
three  or  four  drops  have  been  given. 

Local  anesthesia  of  the  nasal  mucous  membrane  may  be  pro- 
duced by  applying  a  4  per  cent,  solution  of  cocain  upon  swabs  of 
cotton  directly  to  the  part  to  be  anesthetized.  Spraying  is  not 
so  desirable,  as  the  solution  is  Kable  to  ran  down  into  the  pharynx 
through  the  posterior  nares  and  produce  a  very  unpleasant 
sensation  in  the  throat,  and,  at  the  same  time,  the  amount  of 
solution  necessary  to  produce  anesthesia  being  larger,  the  danger 
of  poisoning  is  greater.  To  increase  the  efi'ectiveness  of  the 
cocain  and  obtain  a  bloodless  field  of  operation,  a  spray  of  a  i  to 
iCMDo  adrenalin  solution  may  be  employed  after  the  cocainization. 

In  the  larynx  cocain  may  be  applied  more  freely  without  danger 
than  is  the  case  when  it  is  applied  to  the  nasal  mucous  membrane. 
Small  quantities  of  a  10  per  cent,  solution  may  be  applied  by  means 
of  a  spray,  or,  better,  applied  directly  to  the  desired  spot  on  a  swab, 
with  the  aid  of  a  laryngeal  mirror. 


The  anterior  urethra  may  be  sufficiently  anesthetized  by  filling  it 
with  a  0.2  per  cent,  cocain  and  adrenalin  solution,  introduced  by 
means  of  a  urethral  syringe.  The  solution  should  be  confined  in  the 
urethra  for  at  least  fifteen  minutes,  by  holding  the  meatus  closed. 
The  posterior  urethra  may  be  anesthetized  by  instilling  into  it  a  few 
drops  of  a  I  per  cent,  cocain  and  adrenalin  solution  or  a  2  per  cent, 
novocain  adrenalin  solution  by  means  of  an  instillation  syringe  or 
through  a  soft  rubber  catheter. 

For  the  bladder,  a  o.i  per  cent,  cocain  and  adrenalin  solution  is 
sufficient.  Five  ounces  (150  c.c.)  of  such  a  solution  to  which  is  added 
twenty  drops  (1.25  c.c.)  of  adrenalin  is  slowly  introduced  warm  by 
means  of  a  catheter,  the  bladder  having  been  previously  irrigated. 
The  operator  should  then  wait  fifteen  to  twenty  minutes  for  the  drug 
to  take  effect. 


Infiltration  anesthesia  was  devised  by  Schleich  after  a  series  of 
careful  experiments  with  salt  solutions  of  different  strengths,  com- 
bined with  minute  quantities  of  morphin,  cocain,  and  carbolic  acid. 
From  his  work  has  been  evolved  the  weak  cocain  solution,  as  used  at 
the  present  time,  which  has  made  possible  the  safe  employment  of 
cocain  in  really  extensive  operations. 

By  infiltration  is  meant  the  production  of  analgesia  in  a  part  by 
edematization  of  the  tissues  with  weak  anesthetic  solutions.  The 
fluid  is  introduced  into  the  tissues,  carefully  avoiding  important  vas- 
cular structures,  without  particular  reference  to  the  nerve  trunks. 
The  resulting  anesthesia  is  partly  due  to  the  direct  action  of  the  drug 
upon  the  nerve  endings,  partly  to  the  pressure  of  the  fluid,  and  also  to 
the  interference  with  the  blood  supply.  The  anesthesia  may  be  in- 
creased and  indefinitely  prolonged  if  the  circulation  be  kept  stationary 
by  some  form  of  constriction  applied  to  the  part,  centrally  to  the  seat 
of  injection,  or  by  incorporating  in  the  fluid  infiltrated  vasoconstrictor 
drugs  like  adrenalin.  With  the  infiltration  method  of  anesthesia  it 
is  necessary  to  thoroughly  edematize  or  literally  pack  the  tissues  with 
the  anesthetic  fluid,  for,  without  this,  the  weak  solution  employed 
would  be  worthless. 

Apparatus. — For  the  purposes  of  ordinary  infiltration  the  6oTn, 
(4  c.c.)  or  the  10  c.c.  (2  1/2  dram)  sub-Q  syringe  is  very  satisfactory. 
This  syringe  has  a  solid  glass  barrel  and  glass  piston  with  asbestos 
packing,  and  can  be  readily  sterilized,  and  is  cheap.     Several  of  these 



syringes  should  be  on  hand  for  the  operation,  and  are  to  be  kept  filled 
in  readiness,  so  that  the  infiltration  may  be  carried  on  rapidly  without 
waiting  to  recharge  the  same  syringe.  The  needles  should  be  sharp 
and  fine,  with  a  very  short  bevel,  and  they  should  fit  the  syringe  with- 
out any  leakage  at  the  joint.     It  will  be  convenient  to  have  a  short 

Fig.  41. — Apparatus  for  infiltration. — i,  Medicine  glasses  for  cocain  solutions; 
2,  ampule  of  sterile  cocain  and  salt  crystals;  3,  dropper  for  adrenalin;  4,  syringe 
armed  with  a  short  needle;  5,  long  fine  needle  for  deep  infiltration. 

needle,  i  inch  (2.5  cm.)  long,  for  skin  infiltration,  and  a  second  one, 
2  to  2  1/2  inches  (5  to  6  cm.)  long,  for  infiltration  of  the  deeper 

For  massive  infiltration  a  large  syringe  or  a  special  apparatus 

Fig.  42. — The  Matas  massive  infiltrator. 

which  will  allow  a  continuous  and  rapid  infiltration  of  the  tissues  is 
more  satisfactory.  The  ]Matas  infiltrator  (Fig.  42)  consists  of  a 
heavy  glass  graduated  receptacle  for  the  solution  with  an  air-tight 
screw  cap.  Into  this  cap  is  fitted  a  T-tube  with  two  stopcocks,  one 
for  the  introduction  of  air,  and  one  for  the  escape  of  the  fluid.     A 



rubber  inflating  apparatus  is  attached  to  the  first  cock,  and  to  the 
other  is  a  needle  connected  by  a  suitable  length  of  hose.  The  reser- 
voir is  filled  about  three-fourths  full  and  is  then  charged  with  air, 
and  the  bulb  and  tubing  are  removed.  Infiltration  is  performed  by- 
inverting  the  apparatus  and  opening  the  outflow  stopcock.  Several 
needles  of  different  lengths,  shapes,  and  sizes  are  provided  with  this 
instrument.  The  author  uses  an  infiltrator  made  on  much  the  same 
principles  as  the  Matas  instrument. 
It  consists  of  a  long  graduated  glass 
cylinder  capable  of  holding  lo  ounces 
(300  c.c),  with  an  outlet  at  the  bot- 
tom and  a  rubber  stopper  fastened  in 
the  top  by  a  clamp.  A  small  glass 
tube  connected  with  an  inflating  bulb 
passes  through  this  stopper  (Fig.  43). 
The  reservoir  is  almost  filled  with  the 
solution,  leaving  about  one  quarter 
for  air  space,  and  the  instrument  is 
charged  with  sufficient  air  to  cause 
the  fluid  to  flow  through  the  needle 
in  a  strong  stream. 

Asepsis. — The  syringes,  needles, 
and  receptacles  in  which  the  solu- 
tions are  mixed  should  be  boiled  in 
pure  water  without  the  addition  of 
soda  or  other  alkali. 

Technic. — In  all  cases  where  an 
extensive  or  prolonged  operation  is 
contemplated  morphin,  gr.  1/4 
(0.0162  gm.),  should  be  given  hypo- 
dermically  half  an  hour  beforehand, 

unless  contraindicated.  For  the  skin  infiltration,  a  warm  0.2  per 
cent,  solution  of  cocain  and  adrenalin  or  a  i  per  cent,  novocain 
adrenalin  solution  in  normal  salt  solution  may  be  used.  The 
syringe  is  filled  with  solution  and  the  needle  is  shown  to  the  pa- 
tient with  an  explanation  of  just  what  is  intended  to  be  done.  This 
is  necessary  in  order  to  avoid  an  often  unexpected  shock  from  the 
first  prick  of  the  needle.  The  needle,  held  almost  parallel  to  the 
surface,  is  pushed  into  the  skin  just  beneath  the  epidermis — not 
beneath  the  skin — so  as  to  anesthetize  the  sensitive  end  organs.  If 
the  needle  lies  properly,  its  point  will  be  almost  visible  immediatcl}' 

Fig.  43. — The    author's   apparatus 
for  massive  infiltration. 



below  the  skin  surface.  A  few  drops  of  solution  are  injected  and  the 
skin  becomes  blanched  and  raised  into  a  wheal  about  the  size  of  a 
ten-cent  piece  (Fig.  44).  The  needle  is  then  reinserted  into  the 
edge  of  the  wheal  and  more  solution  injected  in  the  same  manner, 

Fig.  44. — Showing  the  method  of  infiltrating  the  skin.  The  needle  is  inserted 
in  such  a  way  that,  with  the  injection  of  a  few  drops  of  solution,  a  wheal  the  size 
of  a  ten-cent  piece  is  produced. 

until  the  entire  line  of  the  proposed  incision  is  one  continuous  wheal 
(Fig.  45).  In  this  way,  only  the  first  prick  of  the  needle  is  felt  by 
the  patient. 

The  subcutaneous  tissue,  which  is  in  itself  insensitive  but  carries 
sensitive  nerve  trunks  and  blood-vessels,  is  next  very   thoroughly 

Fig.  45. — Showing  the  reinsertion  of  the  needle  into  the  edge  of  the  wheal. 

infiltrated,  using  a  longer  and  somewhat  larger  needle.  For  this 
purpose  cocain  and  adrenalin  in  a  i  to  1000  solution  for  ordinary 
cases  and  in  a  i  to  3000  to  i  to  loooo  solution  for  massive  infiltration 
of  large  areas  or  a  1/4  to  1/8  per  cent,  novocain  adrenalin  solution  may 



be  used.  The  needle  is  inserted  into  the  line  of  the  skin  cocainiza- 
tion,  and  the  solution  is  injected  in  all  directions  from  this  point,  so 
as  to  practically  surround  the  area  of  proposed  incision  with  anesthetic 
solution.  Special  care  is  taken  to  thoroughly  infiltrate  known 
sensitive  regions,  as,  for  instance,  in  the  operation  for  inguinal  hernia 
about  the  external  ring  where  the  main  nerve  trunks  break  up  into 

Fig.  46. — Showing  the  directions  in  which  the  needle  should  be  inserted  in  massive 
infiltration  of  deep  structures. 

their  terminal  filaments.  In  the  case  of  an  operation  upon  a  cir- 
cumscribed growth,  the  infiltration  is  carried  out  in  such  a  way  as  to 
completely  encircle  the  diseased  area  and  isolate  it  from  nerve  com- 
munication with  the  surrounding  parts.  In  like  manner  fascia„ 
muscles,  down  to  or  including  the  periosteum,  may  be  infiltrated  in 
a  mass,  after  the  method  of  Matas  (Fig.  46),  or  each  structure  sepa- 

FiG.  47. — Showing  the  application  of  a  constricting  band  to  the  finger  in  order  to 
prolong  and  intensify  the  anesthesia. 

lately  as  it  is  exposed  during  the  course  of  the  operation.  Muscle, 
tendon,  bone,  and  cartilage  have  no  sensation,  but  their  coverings 
are  extremely  sensitive;  hence  particular  care  must  be  taken  to  in- 
filtrate fascia,  muscle,  and  tendon  sheaths,  periosteum,  and  joint 
capsules,  and  when  operating  upon  joints  to  anesthetize  the  synovial 
membranes  by  a  preliminary  instillation  of  weak  cocain  solution 


into  the  joint  before  operation.  With  proper  infiltration  the  whole 
field  is  thoroughly  edematized  and  is  changed  into  a  tumor-like  mass 
that  is  perfectly  anesthetic. 

While  the  infiltration  method  is  carried  out  without  any  attempt 
to  specially  anesthetize  nerve  trunjis,  the  larger  ones  should  never- 
theless be  injected  after  the  method  to  be  described  whenever  they 
are  encountered  during  the  operation. 

Upon  an  extremity,  more  complete  and  prolonged  anesthesia  may 
be  obtained  if.  after  infiltration,  stasis  of  the  circulation  is  produced 
bv  means  of  elastic  constriction  applied  centrally  to  the  seat  of  in- 
filtration (Fig.  47).  In  such  a  case,  where  large  quantities  of  solu- 
tion are  used  and  remain  in  the  tissues  when  the  operation  is  com- 
pleted, it  is  a  wise  precaution  to  loosen  the  constriction  gradually 
and  intermittently,  so  as  not  to  rapidly  flood  the  system  with  a  large 
volume  of  cocain  solution. 


The  discovery  that  injections  of  cocain.and  similar  analgesics  into 
the  tissues  surrounding  a  nerve  (perineural  infiltration)  or  directly 
into  it  (endoneural  infiltration)  will  efi"ectually  block  the  particular 
nerve  and  produce  anesthesia  in  the  entire  area  of  its  distribution  has 
ftiade  possible  many  operations  of  magnitude,  such  as  those  for  hernia, 
amputations,  etc.  Successful  nerve  blocking  presupposes  an  accu- 
rate knowledge  of  the  course  and  distribution  of  the  sensory  nerves. 
It  may  be  performed  at  a  distance  from  the  seat  of  operation  by  in- 
jecting the  cocain  solution  around  the  nerve,  or  by  cutting  down  and 
exposing  the  nerve  before  injection;  or  the  blocking  may  be 
performed  by  separately  injecting  each  nerve  as  it  is  exposed  during 
the  course  of  the  operation.  The  action  of  the  anesthetic  is  in- 
tensified and  indefinitely  prolonged  by  arresting  the  circulation  in 
the  injected  and  anesthetized  nerve  trunks  by  means  of  elastic  con- 
striction, as  already  spoken  of  under  infiltration,  and  to  a  lesser 
degree  by  the  addition  of  adrenahn  to  the  analgesic  solution. 

The  perineural  method  of  infiltration  is  more  suited  to  regions  sup- 
plied by  the  smaller  superficial  nerv'es  and  to  the  smaller  extremities, 
as  the  fingers  and  toes.  For  anesthetizing  the  large  nerve  trunks 
with  thick  sheaths,  direct  injection  of  the  nerv^es  as  they  are  exposed 
in  the  field  of  operation,  or  at  some  point  along  the  course  of  the  nerve 
central  to  the  seat  of  operation,  will  give  more  certain  results.  When 
a  region  is  supplied  by  several  nerves,  each  will  have  to  be  separately 
isolated  and  blocked. 



Apparatus. — The  ordinary  60T11  (4  c.c.)  or  10  c.c.  (2  1/2  dr.) 
"Sub-Q"  syringe,  with  a  fairly  long  needle  will  be  found  most 

Asepsis. — The  needles,  syringes,  and  solution  glasses  are  sterilized 
by  boiling  in  pure  water  without  the  addition  of  soda  or  other  alkali. 

Technic. — In  the  perineural  method  of  infiltration  the  analgesic 
solution  is  injected  in  such  a  way  as  to  surround  the  nerve  trunk  or 
"envelop  the  nerve  in  an  anesthetic  atmosphere,"  as  Matas  expresses 
it.  A  spot  in  the  skin  from  which  the  nerve  can  be  reached  with  the 
hypodermic  needle  is  infiltrated  as  already  described,  and  through 
this  area  the  needle  is  inserted  toward  the  known  location  of  the  par- 
ticular nerve  to  be  anesthetized.  The  syringe  is  charged  with  a  0.2 
per  cent,  solution  of  cocain  and  adrenalin  or  a  i  per  cent,  novocain 

Fig.  48. — Method  of  infiltrating  a  large  nerve  trunk.  The  anesthetic  solution 
should  be  injected  into  the  nerve  in  all  directions  so  that  the  entire  nerve  is  ren- 
dered anesthetic  below  the  point  of  injection. 

adrenahn  solution  and  from  15  to  20  drops  are  injected  into  the 
tissues  surrounding  the  nerve.  The  solution  is  allowed  to  become 
diffused,  and  then,  if  the  nerve  be  in  an  extremity,  the  part  is  ex- 
sanguinated by  elevation  and  an  elastic  constriction  is  apphed  cen- 
trally to  intensify  and  prolong  the  anesthesia.  In  a  few  moments  the 
entire  region  supplied  by  the  blocked  nerve  becomes  insensible.  It 
may  happen  that,  in  regions  where  constriction  is  inapplicable,  the 
anesthesia  may  not  be  sufficiently  lasting  for  a  prolonged  operation, 
and  it  will  be  necessary  to  repeat  the  injection  more  than  once  to 
maintain  the  anesthesia. 

By  the  endoneural  method,  if  the  nerves  are  injected  in  the  field 
of  operation,  the  technic  is  very  simple,  the  individual  nerves  being 
infiltrated  with  a  few  drops  of  a  0.5  per  cent,  solution  of  cocain  or  a  2 
per  cent,  solution  of  novocain  as  they  are  exposed.     When  the  injec- 


tion  is  made  at  a  point  distal  to  the  seat  of  operation  the  nerve  is 
first  exposed  by  dissection  under  infiltration  anesthesia  and  is  then 
thoroughly  infiltrated,  the  fluid  being  injected  into  all  portions  of 
the  nerve  so  that  an  entire  transverse  section  is  thoroughly 
blocked  (Fig.  48).  Other  nerves  supplying  the  region  of  operation 
are  similarly  dealt  with.  The  part  is  then  exsanguinated  by  eleva- 
tion and  an  elastic  constriction  is  applied  centrally  to  the  point  of 
injection.  In  a  short  time  all  sensation  below  the  seat  of  injection 
becomes  benumbed,  and  operations  of  any  magnitude  may  be 

Practical  Application  of  Infiltration,  Endo=  and  Perineural 
Methods  of  Anesthesia  to  Special  Localities. — The  methods  of 
locally  anesthetizing  a  part  just  described  all  have  their  special  indi- 
cations. The  operator  should  not  employ  one  method  to  the  exclu- 
sion of  the  others,  but  should  make  his  selection  so  as  to  successfully 
meet  the  indications  in  a  particular  case.  In  a  certain  proportion  of 
the  cases  infiltration  alone  will  sufiice;  in  others,  the  nerve  blocking 
can  be  used  to  better  advantage;  but  in  the  majority  of  extensive 
operations  it  will  be  found  that  a  combination  of  infiltration  with 
endoneural  injections  is  essential  to  a  successful  anesthesia  in  a  given 
region.  A  brief  description  of  the  application  of  these  methods  to 
different  regions  of  the  body  will  furnish  some  idea  as  to  the  scope  and 
capabilities  of  each. 

The  Head. — Operations  upon  the  scalp,  such  as  wound  suture, 
the  removal  of  tumors,  cysts,  etc.,  and  even  procedures  requiring 
incision  of  the  periosteum  and  opening  into  the  brain,  may  be  per- 
formed painlessly  under  a  combination  of  infiltration  and  perineural 
anesthesia.  An  accurate  knowledge  of  the  nerve  supply  of  the  region 
is  essential,  however. 

Briefly,  the  scalp  has  the  following  nerve  supply  (Fig.  49).  The 
small  occipital  and  great  occipital  nerves  supply  the  posterior  part 
of  the  scalp  as  far  forward  as  the  vertex.  The  great  auricular  nerve 
suppHes  the  mastoid  region,  as  does  also  the  small  occipital.  The 
parietal  portion  of  the  scalp  receives  its  supply  from  the  auriculo- 
temporal and  a  branch  of  the  temporomalar.  The  supratrochlear 
branch  of  the  frontal  nerve  suppHes  the  integument  of  the  lower  part 
of  the  forehead  on  either  side  of  the  median  line.  The  supraorbital 
supplies  the  cranium  over  the  frontal  and  parietal  bones.  Blocking 
these  nerves  by  cross  strips  of  infiltration  at  the  points  where  they 
penetrate  the  muscular  fascia  and  become  subcutaneous  (Fig.  50), 
or  performing  a  thorough  circumscribed  infiltration  around  the  area 



of  operation,  with  infiltration  of  the  periosteum,  if  necessary,  renders 
many  cases  amenable  to  local  measures  which  are  now  performed 
under  general  narcosis.  Constriction  by  means  of  a  rubber  tourni- 
quet passed  around  the  forehead  above  the  ears  and  over  the  occipital 
protuberance  will  be  found  most  useful  as  an  aid  to  anesthesia. 

About  the  lips,  chin,  nose,  cheeks,  tongue,  mouth,  and  lower  jaw 
local  means  of  anesthesia  are  often  quite  sufficient.  Blocking  of  the 
mental  nerve  as  it  emerges  from  the  mental  foramen  will  render 
insensitive  the  region  of  the  chin  and  the  skin  and  mucous  membrane 

Fig.  49.  Fig.  50. 

Fig.  49. — The  superficial  ner\'es  of  the  scalp  and  face,  i,  Supratrochlear  nerve; 
2,  supraorbital  nerve;  3,  temporal  branch  of  the  temporomalar  nerve;  4,  auriculo- 
temporal nerve;  5,  great  auricular  nerve;  6,  small  occipital  nerve;  7,  great  occipi- 
tal nerve;  8,  infratrochlear  nerve;  9,  infraorbital  nerve;  10,  nasal  nerve;  11, 
mental  nerve. 

Fig.  50. — Showing  the  area  of  anesthesia  after  blocking  the  supratrochlear, 
supraorbital,  and  mental  nerves.     The  dots  indicate  the  points  for  infiltration. 

of  the  lower  lip  of  the  same  side  (see  Fig.  50).  In  like  manner  the 
upper  lip  may  be  anesthetized  by  blocking  of  the  infraorbital 
nerves.  The  inferior  dental  nerve  is  readily  reached  for  blocking  as 
it  enters  the  inferior  dental  foramen  at  the  outer  side  of  the  spine  of 
Spix.  This  point  lies  near  the  median  line  of  the  internal  surface  of 
the  ramus  of  the  jaw  about  haK  an  inch  (i  cm.)  above  the  upper  surface 
of  the  last  molar  tooth  (Fig.  51).  The  lower  jaw  may  be  thus  anes- 
thetized and  teeth  may  be  painlessly  extracted.     The  Ungual  nerve 



may  be  perineurally  infiltrated  at  about  the  same  point,  as  it  lies 
close  to  the  inferior  dental.  The  floor  of  the  mouth  and  the  tongue 
are  thus  rendered  insensitive,  and  quite  extensive  operations  may 
be  performed.  Infiltration  alone,  however,  is  often  sufl5cient  in  the 
smaller  operations  about  the  lips  and  mouth. 

Blocking  of  the  branches  of  the  trifacial  nerve  at  their  points  of 
exit  from  the  base  of  the  skull  gives  a  wide  area  of  anesthesia  and 
permits  the  painless  performance  of  very  extensive  operations  in  the 
region  supplied  by  these  nerves,  such  as  removal  of  the  tongue, 
resection  of  the  upper  and  lower  jaws,  operations  upon  the  orbit, 
etc.     As  early  as  1900  Matas  reported  a  resection  of  both  upper 

Fig.  51. — Showing  the  method  of  blocking  the  inferior  dental  nerve. 

jaws  after  cocainization  of  the  second  division  of  the  fifth  nerve. 
More  recently  Braun  and  others  have  reported  extensive  operations 
performed  by  similar  methods.  The  technic  of  reaching  these  nerves 
is  similar  to  that  employed  by  Schlosser,  Patrick,  and  others  in  the 
use  of  alcoholic  injections  for  trifacial  neuralgia  (see  page  197). 

The  Neck. — Operations  upon  the  neck  for  the  removal  of  benign 
growths,  isolated  freely  movable  glands,  or  for  the  ligation  of  vessels 
are  performed  by  infiltration  of  the  lines  of  incision  combined  with 
massive  infiltration  of  the  surrounding  tissues.  As  already  men- 
tioned, thyroidectomy  and  tracheotomy  may  be  carried  out  by 
following  the  same  principles.     In  superficial  operations  upon  the 


anterior  and  posterior  triangles,  perineural  blocking  by  a  strip  of 
infiltration,  or  direct  injection  of  the  superficial  branches  of  the  cervi- 
cal plexus  as  they  escape  from  the  posterior  border  of  the  sterno- 
mastoid  muscle  at  or  about  its  middle  will  be  of  great  aid  (Fig.  53). 
Operations  upon  the  larynx  may  be  performed  under  infiltration 
anesthesia  combined  T\ath  blocking  of  the  superior  laryngeal  nerve 
at  the  tip  of  the  greater  cornu  of  the  hyoid  bone. 

Fig.  52.  Fig.  53. 

Fig.  52. — The  superficial  cervical  plexus.  The  dotted  lines  indicate  the  course 
of  the  stemomastoid  muscle. 

Fig.  53. — Showing  the  area  of  anesthesia  after  blocking  the  superficial  cervical 
plexus.     The  dots  indicate  the  points  for  infiltration. 

The  Thorax. — Exploratory  punctures,  aspiration  of  the  peri- 
cardium and  pleura,  rib  resection  for  empyema,  and  the  removal  of 
benign  growths  from  the  breast  may  all  be  satisfactorily  performed 
under  infiltration.  In  the  operation  of  rib  resection  the  infiltration 
should  be  carried  out  layer  by  layer,  including  the  periosteum. 
Perineural  blocking  of  the  intercostal  nerves  as  they  pass  between  the 
intercostal  muscles  in  the  upper  portion  of  the  intercostal  space,  or 
endoneural  injection  of  each  nerve  as  it  is  exposed,  will  assist  in  ren- 
dering the  operation  painless  where  more  than  one  rib  is  to  be  re- 
sected. For  a  perineural  injection  the  needle  is  inserted  close  to 
the  lower  margin  of  the  rib  about  one  and  one-fifth  inches  (3  cm.) 
from  the  median  line  and  is  pushed  in  for  a  distance  of  i  ^/^  to  2  in. 
(4  to  5  cm.)  when  it  strikes  the  bone.  An  attempt  is  next  made  to 
guide  the  needle  below  the  lower  edge  of  the  rib.  The  injection  is 


then  commenced  and  is  continued  as  the  needle  is  carried  inward 
and  toward  the  median  Hne  well  into  the  subcostal  angle  for  a  distance 
of  1/4  to  1/2  an  inch  (6  to  12  mm.).  As  many  of  the  other  inter- 
costal nerves  as  may  be  necessary  are  similarly  blocked.  After  the 
periosteum  over  the  rib  is  incised  and  reflected,  the  rib  may  be  ex- 
sected  without  pain.  The  parietal  pleura,  like  the  peritoneum,  is 
very  sensitive  and  requires  infiltration  before  incision. 

The  Upper  Extremity. — Almost  any  operation  may  be  performed 
in  this  region  under  a  skilful  use  of  local  anesthesia.  The  brachial 
plexus  may  be  anesthetized  by  exposing  it  under  infiltration  anes- 
thesia above  the  clavicle  (Fig.  54)  and  blocking  each  branch  sepa- 
rately by  direct  injection  with  a  0.5  per  cent,  solution  of  cocain  or  a 

Fig.  54. — Exposure  of  the  brachial  plexus  for  infiltration,  i,  External  jugular 
vein;  2,  transversalis  colli  artery;  3,  scalenus  anticus  muscle;  4,  fifth  cervical 
root;  5,  sixth  cervical  root;  6,  seventh  cervical  root;  7,  clavicle. 

2  per  cent,  solution  of  novocain,  or  by  a  perineural  injection  after  the 
method  of  Kulenkampff.  His  technic  is  as  follows:  The  patient  is 
placed  in  the  sitting  position  and  the  subclavian  artery  is  located  by 
palpation.  This  is  usually  at  a  point  where,  if  the  external  jugular 
vein  were  extended,  it  would  strike  the  clavicle.  The  needle  is 
inserted  just  outside  this  point  immediately  above  the  clavicle  in 
an  obhque  direction  slightly  back  and  downward  in  a  line  which,  if 
carried  back,  would  strike  the  spines  of  the  2d  or  3d  dorsal  vertebra. 
At  a  distance  of  about  i  1/5  inches  (3  cm.)  the  needle  should  reach 
the  nerve  trunks.  Paresthesia  throughout  the  arm  and  motor  phe- 
nomena indicate  when  this  has  been  accomphshed.^  If  the  needle 
strikes  the  first  rib  it  has  been  introduced  too  far.     Kulenkampft"  in- 

1  Injury  to  the  phrenic  nerve  with  embarrassed  respiration  and  diminished 
breath  sounds  has  been  reported  following  perineural  injection  of  the  brachial  plexus, 
so  that  care  should  be  taken  to  determine  the  presence  of  paresthesia  before 
making  the  injection  and  not  to  anesthetize  both  sides  at  the  same  time. 



jects  2  1/2  drams  (10  c.c.)  of  a  2  per  cent,  solution  of  novocain  and 
adrenalin.  In  10  to  30  minutes  all  sensation  in  the  area  below  the 
point  of  injection  is  destroyed,  and  amputations  or  other  operations 
may  be  performed  at  any  level  below  the  seat  of  injection.  In  shoul- 
der-girdle amputations,  however,  infiltration  of  the  hnes  of  incision 
also  should  be  performed  in  order  to  block  small  branches  from  the 
cervical  plexus,  i.e.,  the  supraacromial  and  suprascapular  nerves. 

Operations  upon  the  forearm  require  blocking  of  the  median,  ul- 
nar, and  musculospiral  nerves.  This  may  be  accomplished  by  block- 
ing the  brachial  plexus  as  already  described,  by  directly  injecting  all 
three  nerves  after  exposure  under  infiltration  anesthesia  in  the  upper 


Fig.  56. 

Fig.  55. — -Exposure  of  the  musculospiral  and  median  nerves  at  the  elbow. 
Musculospiral  nerve;  2,  median  nerve. 

Fig.  56. — Exposure  of  the  ulnar  nerve  just  aJ)Ove  the  internal  condyle. 

portion  of  the  arm,  or  by  separately  exposing  and  blocking  each  nerve 
just  above  the  elbow.  In  following  the  latter  method,  the  median 
nerve  is  exposed  by  an  incision  across  the  elbow  to  the  inner  side  of 
the  biceps  muscle,  the  brachial  artery  lying  jast  external  to  it;  the 
ulnar,  in  the  groove  between  the  internal  condyle  and  the  olecranon; 
and  the  musculospiral,  between  the  biceps  tendon  and  the  supinator 
longus  muscle.  Blocking  each  nerve  with  a  0.5  per  cent,  solution  of 
cocain  or  a  2  per  cent,  solution  of  novocain  produces  complete  in- 
sensibility of  the  extremity  below  the  point  of  injection  excepting 
the  skin  and  subcutaneous  tissues  of  the  upper  central  portion  of  the 
forearm,  supplied  by  the  musculocutaneous  and  internal  cutaneous 



nerves.  A  circular  area  of  subcutaneous  infiltration  at  the  elbow, 
however,  as  advised  by  ^Matas,  abolishes  any  remaining  sensibility 
in  this  region  (Fig.  57). 

Just  above  the  wrist,  the  median,  ulnar,  and  radial  nerves  are 
available  for  perineural  injection.     The  median  is  reached  by  intro- 

Fic.  57. — Showing  the  method  of  anesthetizing  the  small  superficial  nerves  by  cir- 
cular strips  of  subcutaneous  infiltration. 

ducing  the  needle  to  the  ulnar  side  of  the  tendon  of  the  palmaris 
longus  and  inserting  it  obUquely  for  a  distance  of  1/2  to  3/4  inch 
(i  to  2  cm.)  in  the  direction  of  the  radius.  The  ulnar  nerve  may  be 
anesthetized  perineurally  a  little  above  the  head  of  the  ulna  by  insert- 

FiG.  58. — Cross-section  of  the  forearm  above  the  wrist  showing  the  direction 
of  the  needle  for  perineural  infiltration  of  the  ulnar  and  median  nerves.  (After 
Braun.)  i,  Interosseousnerve;  2,  radial  nerve;  3,  radial  artery;  4,  median  nerve; 
5,  ulnar  ner\^e;  6,  areas  of  skin  infiltration;  7,  flexor  carpi  ulnaris  tendon;  8  pal- 
maris longus  tendon;  9,  flexor  carpi  radialis  tendon. 

ing  the  needle  to  a  depth  of  about  4/5  inch  (2  cm.)  between  the  ulna 
and  the  tendon  of  the  flexor  carpi  ulnaris.  The  radial  nerve  and  its 
branches  are  best  caught  by  a  cross  strip  of  subcutaneous  infiltra- 
tion just  above  the  styloid  process  of  the  radius  (Fig.  58).  Perineural 
injection  alone  for  operations  upon  the  wrist  is  not  satisfactory,  as 



this  region  is  also  supplied  by  small  branches  given  off  from  these 
nerves  higher  up.  A  circular  strip  of  subcutaneous  infiltration  above 
the  wrist,  however,  will  render  the  anesthesia  complete  (see  Fig.  57). 

Fig.  59. — Points  for  inserting  the  needle  in  perineural  infiltration  of  the  digital 


In  thin  individuals,  massive  circular  infiltration  alone  is  generally 
sufficient  to  produce  anesthesia  below  the  site  of  injection. 

Anesthesia  of  the  fingers  is  obtained  by  infiltrating  two  points  in 
the  skin  on  the  dorsal  surface  near  the  base  of  each  finger  (Fig.  59). 

Fig.  60. — Cross-section  of  the  finger  showing  the  direction  of  the  needle  for 
perineural  infiltration  of  the  digital  nerves.  (After  Braun.)  i,  Extensor  tendons; 
2,  bone;  3,  flexor  tendons;  4,  areas  of  skin  infiltration. 

Through  these  points  the  needle  is  inserted  toward  each  of  the  four 
digital  nerves,  and  the  anesthetic  solution  injected  (Fig.  60).  All 
nerve  communication  is  thus  blocked  and  the  finger  may  be  incised, 
amputated,  etc.,  without  pain.     By  injecting  in  the  known  location 


of  the  digital  nerves  as  they  pass  between  the  metacarpal  bones,  the 
bases  of  the  fingers  and  even  the  metacarpals  may  be  anesthetized. 

The  Abdomen. — The  abdomen  may  be  opened  in  any  region  by 
simple  infiltration,  combined  with  endoneural  injection  of  nerves  as 
they  are  exposed.  The  skin,  the  subcutaneous  tissues,  the  fasciae, 
the  muscular  layers,  and  the  peritoneum  should  be  separately  in- 
filtrated, layer  by  layer.  More  perfect  anesthesia  may  be  obtained 
by  combining  with  the  infiltration  a  paravertebral  injection  of  the 
nerves  supplying  the  field  of  operation  after  the  method  of  Kappis. 
For  work  about  the  kidney  or  upper  abdomen  the  last  five  thoracic 
and  upper  two  lumbar  nerves  should  be  blocked.  The  technic  is 
as  follows:  The  needle  is  inserted  about  i  2/5  in.  (3.5  cm.)  from  the 
median  hne  on  a  level  with  the  lower  border  of  the  rib  and  is  inserted 
for  a  distance  of  i  3/5  to  2  in.  (4  to  5  cm.)  when  the  bone  should  be 
reached.  The  needle  is  then  made  to  pass  beneath  the  lower  border 
of  the  rib  and  the  injection  is  begun.  The  solution  is  slowly  injected 
while  the  needle  is  pushed  onward  for  a  distance  of  1/4  to  1/2  in. 
(6  to  12  m.m.)  slightly  toward  the  median  line  into  the  subcostal 
angle.  The  same  method  is  employed  for  the  lumbar  nerves,  the 
transverse  processes  of  the  vertebrae  being  the  guides  instead  of  the 
ribs.  The  limitations  of  local  anesthesia  in  abdominal  surgery  have 
already  been  considered  (page  62)  and  will  not  be  reiterated  here. 

Hernia. — While  operations  for  hernia  of  any  variety  may  be 
carried  out  under  local  anesthesia,  the  inguinal  will  be  found  espe- 
cially suited  to  this  method  of  anesthesia,  the  umbilical  and 
femoral  varieties  less  so. 

For  inguinal  hernia  a  combination  of  infiltration  and  endoneural 
injection  is  possible  on  account  of  the  anatomical  arrangement  of  the 
inguinal  region,  which  is  supplied  by  three  fairly  large  nerve  trunks 
having  a  rather  constant  course — namely,  the  iliohypogastric,  the 
iHoinguinal,  and  the  genitocrural.  The  iliohypogastric  will  be  found 
in  the  upper  angle  of  the  hernial  incision  after  reflecting  the  aponeu- 
rosis of  the  external  oblique,  usually  running  downward  and  inward 
on  a  line  drawn  from  about  the  anterior-superior  spine  to  a  point 
an  inch  (2.5  cm.)  above  the  external  ring.  The  ilioinguinal  will 
usually  be  found  in  the  line  of  incision  just  beneath  the  aponeurosis 
of  the  external  oblique,  and  on  a  lower  level  than  the  iliohypogastric, 
running  downward  in  the  long  axis  of  the  hernia  (Fig.  61).  It  may 
even  lie  as  far  out  as  Poupart's  ligament.  This  nerve  is  often  smaller 
than  the  iliohypogastric,  and  in  some  cases  it  may  be  absent,  in  which 
event  its  place  is  taken  by  the  genitocrural.     The  genitocrural  will  be 



found  after  reflecting  the  aponeurosis  of  the  external  oblique  lying 
among  the  structures  of  the  cord,  and  frequently  it  lies  behind  the 
cord.  Infiltration  anesthesia  is  employed  until  the  aponeurosis  of 
the  external  obhque  is  reflected,  when  the  above  nerves  are  separately 
blocked.  In  performing  the  infiltration,  special  care  should  be  taken 
to  inject  plenty  of  solution  in  the  region  of  the  external  ring  where 
the  nerves  break  up  into  their  terminal  filaments.  After  the  nerves 
are  properly  blocked,  the  remainder  of  the  operation  may  be  pain- 
lessly performed  without  the  use  of  additional  anesthesia,  though  it 
is  better  to  infiltrate  about  the  neck  of  the  sac  before  ligating  and 
removing  that  structure.  Omentum  may  be  amputated,  adhesions 
within  the  sac  separated,  and  gut  resected  if  necessary,  without  pain. 

Fig.  61. — Showing  the  nerve  supply  of  the  inguinal  region.  (After  Gushing.) 
I,  Iliohypogastric  nerve;  2,  ilioinguinal  nerve;  3,  conjoined  tendon;  4,  cremaster 
muscle;  5,  aponeurosis  of  the  external  oblique  incised  and  edges  reflected. 

Femoral  hernia  may  be  operated  on  under  simple  infiltration  of 
the  skin,  subcutaneous  tissues,  and  sac;  or,  preferably,  by  a  combi- 
nation of  infiltration  and  endoneural  injection.  If  this  latter  method 
is  employed,  the  incision  is  placed  so  as  to  expose  in  addition  the 
external  abdominal  ring.  The  aponeurosis  of  the  external  obhque 
is  thus  exposed  and  is  incised  for  a  short  distance,  so  that  the  ilio- 
inguinal and  genitocrural  nerves  may  be  identified  and  injected. 
Blocking  of  these  nerves,  combined  with  infiltration,  renders  the 
field  of  operation  more  nearly  anesthetic  than  infiltration  alone. 

In  operations  for  umbilical  and  ventral  hernias,  the  infiltration 



method  is  employed.  The  structures  are  separately  injected,  as 
would  be  done  for  an  abdominal  operation,  taking  special  care  to 
thoroughly  infiltrate  about  the  neck  of  the  sac. 

Fig.  62. — Showing  the  method  of  infiltrating  about  the  cord  in  operations  upon 

the  testicle. 

The  Scrotum. — Any  of  the  operations  about  the  scrotum  and 
testicles,  such  as  those  for  varicocele,  hydrocele,  castration,  etc., 
may  be  carried  out  by  perineural  injection  around  the  cord  as  it 
escapes  from  the  external  ring  (Fig.  62),  combined  with  infiltration 
along  the  site  of  incision. 


Fig.  63. — Points  for  injection  in  infiltration  about  the  anus. 

Penis  and  Urethra. — Circumcision  may  be  performed  by  infiltrat- 
ing the  skin  and  mucous  membranes  along  the  hues  of  proposed  in- 
cision, being  careful  to  infiltrate  the  frenum  thoroughly.     More  ex- 


tensive  operations  upon  the  pendulus  portion  may  be  performed  by 
subcutaneous  infiltration  of  a  ring  about  the  base  of  the  penis,  care- 
fully injecting  the  solution  around  each  of  the  dorsal  nerves.  Exter- 
nal urethrotomy  may  be  performed  under  infiltration  combined 
with  topical  anesthesia  of  the  mucous  membrane  (see  page  71). 

Rectum  and  Anus. — The  limitations  of  local  anesthesia  in  rectal 
operations  have  been  previously  pointed  out.  For  the  removal  of 
external  hemorrhoids,  skin  tabs,  etc.,  injecting  a  small  amount  of 
anesthetic  solution  into  the  base  of  the  growth  is  sufficient.  When 
it  is  necessary  to  stretch  the  sphincter,  anesthesia  may  be  obtained 
in  the  following  manner:  Four  wheals  are  made  in  the  skin — in 
front,  behind,  and  at  the  sides  (Fig.  63) — and  through  these  points 
the  hypodermic  needle,  guided  by  a  finger  in  the  rectum,  is  carried 
up  along  the  bowel  and  the  sphincter  is  thoroughly   infiltrated. 

Lower  Extremity.— Blocking  of  the  anterior  crural,  the  external 
cutaneous,  and  the  sciatic  nerves,  combined  with  a  circular  strip  of 
subcutaneous  infiltration,  completely  blocks  all  sensation  in  the  lower 
extremity  below  the  level  of  the  "block,"  and  amputations  can  thus 
be  performed  as  high  as  the  lower  and  middle  thirds  of  the  thigh. 
Above  this  point,  however,  the  nerve  supply  is  complicated  and  it 
will  be  necessary  to  massively  infiltrate  along  the  line  of  incision  as 
well  as  to  "block"  the  nerve  trunks  already  mentioned.  The  exter- 
nal cutaneous  nerve  may  be  reached  for  injection  by  an  incision  so 
placed  as  to  expose  the  nerve  as  it  emerges  from  under  the  anterior 
superior  spine  (Fig.  64),  or  it  may  be  blocked  by  a  perineural  injection, 
the  needle  being  inserted  just  to  the  inner  side  of  the  anterior  superior 
spine.  Skin  grafting  may  be  readily  performed  by  blocking  the  nerve 
after  the  manner  just  described  and  taking  the  grafts  from  the  outer 
side  of  the  thigh.  The  anterior  crural  nerve  may  be  exposed  by  an 
incision  placed  about  1/2  inch  (i  cm.)  external  to  the  center  of 
Poupart's  ligament.  The  nerve  will  be  found  just  external  to  the 
femoral  artery.  The  sciatic  nerve  may  be  reached  for  perineural 
injection  by  inserting  the  needle  at  a  point  where  a  horizontal  line 
through  the  tip  of  the  great  trochanter  cuts  a  vertical  line  through 
the  outer  margin  of  the  tuberosity  of  the  ischium.  A  needle  about  3 
inches  (8  cm.)  long  is  reqoired.  It  is  introduced  directly  backward 
until  bone  is  reached  and  is  then  withdrawn  for  a  distance  of  1/25 
inch  (i  mm.).  After  injection  of  the  anesthetic  solution  about  1/2 
an  hour  is  required  for  complete  anesthesia.  The  sciatic  may  also  be 
blocked  after  exposure  under  infiltration  anesthesia  at  the  lower  bor- 
der of  the  gluteus  maximus  muscle,  or  at  the  upper  border  of  the  pop- 



liteal  space.     In  the  former  case,  an  incision  3  to  4  inches  (7.5  to 
10  cm.)  long  is  made  between  the  tuberosity  of  the  ischium  and  the 

Fig.  64. — Exposure  of  the  anterior  crural  and  external  cutaneous  nerves  for 
injection.  i,  Anterior  crural  nerve;  2,  external  cutaneous  nerve;  3,  femoral 
artery;  4,  femoral  vein. 

great  trochanter,  with  its  center  over  the  lower  margin  of  the  gluteus 
maximus  muscles.  By  retracting  the  gluteus  maximus  upward  and 
the  ham-string  muscles  inward,  the  nerve  will  be  found  lying  under 

Fig.  65. — Exposure  of  the  sciatic  nerve  in  the  upper  part  of  the  thigh  for  injec- 
tion. I,  Gluteus  maximus  muscle;  2,  biceps  muscle;  3,  semitendinosus  muscle; 
4,  sciatic  nerve. 

the  outer  edge  of  the  biceps  muscle  (Fig.  65).     In  the  upper  portion 
of  the  popliteal  space  the  nerve  may  be  exposed  by  a  vertical  incision 



in  the  mid-line;  it  will  be  foancl  lying  between  the  biceps  and  semi- 
membranosus muscles.  It  should  be  injected  before  it  divides,  or 
else  both  the  internal  and  external  popliteal  nen-es  are  to  be  blocked. 

Fig.  66. — Exposure  of  the  internal  saphenous  nerve  for  injection,      i,  Internal 
saphenous  nerv^e;  2,  internal  saphenous  vein. 

In  operations  below  the  tubercle  of  the  tibia,  it  is  unnecessary  to  block 
the  anterior  crural  and  external  cutaneous;   blocking  the  sciatic  in 

Fig.  67. — Cross-section  of  the  leg  above  the  ankle-joint,  showing  the  direction 
of  the  needle  for  perineural  infiltration  of  the  posterior  tibial  nerve.  (After  Braun.) 
I,  Posterior  tibial  nerve;  2,  external  saphenous  nerve;  3,  area  of  skin  infiltration; 
4,  musculocutaneous  ner\'e;  5,  anterior  tibial  nerve;  6,  tendo  achillis;  7,  peronei 
muscles;  8,  flexor  longus  haUucis;  9,  extensor  longus  digitorum;  10,  extensor 
longus  hallucis;  li,  tibialis  anticus;  12,  tibialis  posticus;  13,  flexor  longus 

the  popliteal  space  and  the  external  saphenous  as  it  passes  to  the 
inner  and  posterior  aspect  of  the  knee-joint  is  suihcient  (Fig.  66). 
Below  the  knee,  the  large  nerves  are  not  available  for  injection 


until  the  ankle  is  reached.  Behind  the  ankle  the  posterior  tibial  may 
be  perineurally  injected  by  inserting  the  needle  on  the  inner  side  of 
the  tendo  achillis  directly  forward  almost  to  the  posterior  surface  of 
the  tibia  (Fig.  67).  The  anterior  tibial  may  be  likewise  perineurally 
injected  by  inserting  the  needle  on  the  dorsum  of  the?  ankle  between 
the  tendons  of  the  tibialis  anticus  and  the  extensor  longus  hallucis 
and  the  innermost  tendon  of  the  extensor  longus  digitorum.  By  a 
circular  strip  of  subcutaneous  inliltration.  the  remainder  of  the  sen- 
sory nerve  supply  may  be  blocked  and  complete  anesthesia  of  the  foot 
may  be  obtained. 

In  anesthetizing  the  digits  and  metatarsals,  the  same  principles 
already  described  for  the  hand  are  applicable.  Amputations  of  toes, 
operations  for  ingrowing  toe-nail,  osteotomy  for  hallux  valgus,  etc., 
may  be  readily  performed  under  perineural  injection  of  the  proper 

Operations  upon  Inflamed  Tissues  under  Local  Anesthesia. — 
Upon   the  extremities  some  of  the  methods  of  endoneural  or  peri- 

FiG.  68. — Showing  the  method  of  anesthetizing  an  inflamed  area. 

neural  blocking  of  the  nerves  supplying  the  region  affected  gives 
most  satisfaction.  Where  these  methods  are  not  applicable  infiltra- 
tion anesthesia  may  be  employed  if  care  is  taken  not  to  inject  the 
solution  directly  into  the  inflamed  tissues.  An  attempt  should  be 
made  to  surround  the  diseased  area  with  the  anesthetic  solution, 
making  the  injections  through  healthy  skin  into  the  subcutaneous 
tissues  (Fig.  68),  thus  cutting  oflf  all  sensory  communication  wath  the 



surrounding  parts.  Infiltration  of  the  inflamed  tissues  should  be 
avoided  as  any  increase  in  distention  of  the  already  swollen  structures 
causes  intense  pain  and  in  some  cases  seems  to  lower  the  resistance  to 
such  an  extent  that  cellulitis  results. 


Quite  recehtly  Bier  has  developed  an  innovation  in  the  production 
of  local  anesthesia  in  extremities,  termed  venous  anesthesia.  It 
consists  essentially  in  rendering  the  limb  bloodless  and,  after  isolating 
the  field  of  operation  from  the  circulation  by  means  of  tourniquets 
applied  above  and  below  the  area  to  be  anesthetized,  injecting  the 
anesthetic  solution  into  one  of  the  veins  between  the  two  tourniquets. 
What  is  termed  "direct  anesthesia"  rapidly  develops  between  the 
two  bandages;  while  somewhat  later,  after  the  anesthetic  solution 
has  had  time  to  act  upon  and  paralyze  the  nerve  trunks  within  the 
isolated  area,  the  anesthesia  extends  to  the  entire  limb  beyond  the 
bandage.     This  is  termed  "indirect  anesthesia." 

Venous  anesthesia,  of  course,  is  applicable  only  to  the  extremities, 
and  it  is  not  intended  that  it  should  supplant  the  ordinary  methods  of 
local  anesthesia  which  are  sufficient  for  the  superficial  tissues;  its 
special  field  is  for  major  operations,  such  as  amputations,  resection  of 
joints,  and  operations  upon  bones,  muscles,  tendons,  etc.  According 
to  its  originator,  diabetic  and  senile  gangrene  and  arteriosclerosis  are 
contraindications  to  its  use. 

While  this  method  of  anesthesia  has  not  received  the  extended 
trial  in  the  hands  of  different  operators  that  some  of  the  older  meth- 
ods of  local  anesthesia  have,  it  has  been  thoroughly  tested  by  its 
originator  and  by  him  is  considered  to  be  far  ahead  of  other  methods 
for  producing  anesthesia  of  the  extremities.  Bier  reported  {Berliner 
klinische  Wochenschrift,  March  19,  1909)  134  operations  under  venous 
anesthesia,  including  amputations,  arthrotomies,  bone  suture,  extirpa- 
tion of  varicose  veins,  etc.,  and  of  this  total  in  115  cases  the  anesthesia 
was  perfect,  in  fourteen  satisfactory,  and  in  five  unsatisfactory.  Of 
the  latter,  however,  three  were  operations  upon  children.  In  iifteen 
cases  in  which  the  writer  has  employed  this  method  the  anesthesia  was 
all  that  could  be  desired. 

Apparatus. — A  syringe,  such  as  the  Sub-Q  or  the  Janet,  with  a 
capacity  of  about  3  ounces  (90  c.c),  Bier's  special  cannula,  a  short 
heavy  piece  of  rubber  tubing  for  connecting  the  syringe  with  the  can- 
nula, a  small  medicine  glass,    a  small  syringe  and  fine  needle  for  infil- 



trating  the  site  of  operation,  a  glass  graduate  for  the  vein  solution, 
and  three  rubber  bandages,  each  2  1/2  inches  (6  cm.)  wide  and  6 
feet  (180  cm.)  long  (Fig.  69),  will  be  required. 

Bier's  cannulas  are  1/16  inch  (1.5  mm.)  in  diameter  for  children  and 
1/14  to  1/12  inch  (1.75  to  2  mm.)  in  diameter  for  adults.  The  distal 
end  of  the  cannula  is  provided  with  grooves  into  which  the  ligatures 

Fig.  69. — Apparatus  for  venous  anesthesia,  i,  Rubber  tourniquets;  2, 
medicine  glass;  3,  glass  graduate;  4,  large  glass  syringe  and  Bier's  cannula;  5, 
ampule  of  anesthetic;  6,  syringe  for  preliminary  infiltration  of  the  skin  at  the  site 
of  operation. 

with  which  it  is  tied  in  the  vein  fits,  and  at  the  other  end  there  is 
a  stopcock  and  a  bayonet  connection  (Fig.  70).  In  the  absence  of  a 
special  cannula,  an  ordinary  infusion  cannula  may  be  used,  an  artery 
clamp  applied  to  the  rubber  tubing  acting  as  a  stopcock. 

Fig.  70. — Enlarged  view  of  Bier's  cannula  for  venous  anesthesia. 

Instruments. — Instruments  necessary  for  an  ordinary  infusion  are 
required;  namely,  a  scalpel,  mouse-toothed  thumb  forceps,  a  pair  of 
blunt-pointed  scissors,  an  aneurysm  needle,  needle  holder,  two 
curved  needles  with  a  cutting-edge.  No.  2  plain  catgut,  and  a  few 
artery  clamps  (Fig.  71). 

Solution. — Bier  employs  a  0.5  per  cent,  solution  of  novocain  in 
normal  salt  solution. 

bier's  venous  anesthesia 


Quantity  Used. — From  20  to  60  c.c.  (5  drams  to  2  ounces)  of 
solution  are  ordinarily  injected,  depending  upon  the  extent  of  the  area 
to  be  injected.  The  quantity  employed  should  not,  however, 
exceed  2  3/4  ounces  (80  c.c). 

Site  of  Injection. — For  the  arm,  the  basilic  vein  and  for  the  leg 
the  internal  saphenous  vein  is  usually  chosen,  though  any  of  their 
tributaries  sufficiently  large  for  the  purpose  will  answer. 

Preparations. — The  site  of  injection  is  sterilized  by  painting  with 
tincture  of  iodin.  The  instruments  are  boiled,  and  the  operator's 
hands  cleansed  as  for  any  operation. 

Technic. — The  limb  is  first  elevated  and  rendered  bloodless  by 
the  application  of  an  Esmarch  bandage  applied  from  the  extremity  of 

Fig.  71. — Instruments  for  venous  anesthesia,  i,  Scalpel;  2,  blunt-pointed 
scissors;  3,  thumb  forceps;  4,  aneurysm  needle;  5,  needle  holder;  6,  curved 
needles;  7,  No.  2  plain  catgut;  8,  artery  clamps. 

the  limb  up  to  a  point  well  above  the  site  of  injection.  Some  care 
should  be  taken  in  applying  this  bandage  as  it  is  necessary  that  the 
veins  be  thoroughly  emptied.  A  tourniquet  is  then  applied  at  the 
upper  limit  of  the  bandage  used  to  exsanguinate  the  part  by  wrap- 
ping a  soft  rubber  bandage  about  the  limb  in  broad  bands  so  as  not 
to  cause  the  patient  any  unnecessary  discomfort,  and  the  first  band- 
age is  removed  for  a  distance  of  4  to  10  inches  (10  to  25  cm.).  At 
this  point  a  second  tourniquet  is  applied  and  the  remaining  portion 
of  the  Esmarch  is  entirely  removed  (Fig.  72).  When  the  operation 
is  near  an  extremity  only  one  tourniquet  need  be  employed.  It 
should  not  be  placed,  however,  higher  than  the  middle  of  the  fore- 



arm  or  leg.  Under  infiltration  anesthesia  with  a  o.  2  per  cent,  solu- 
tion of  cocain  or  a  i  per  cent,  solution  of  novocain,  one  of  the  main 
subcutaneous  veins  or  one  of  its  large  tributaries,  previously  selected, 
is  exposed  by  a  small  transverse  incision  in  the  proximal  part  of 
the  isolated  area.  The  vein  is  opened  by  cutting  with  scissors,  its 
proximal  end  is  tied  ofif,  and  the  cannula  is  secured  in  its  distal  end. 
Any  small  veins  that  may  be  cut  are  securely  clamped  to  prevent 
leakage  of  the  solution.  The  anesthetic  is  then  injected  under  con- 
siderable pressure  toward  the  periphery,^  i.e.,  against  the  valves  of 
the  veins,  until  the  superficial  veins  swell  and  the  whole  segment 
between  the  two  bandages  becomes  paler  than  before.  The  stopcock 
is  then  closed  and  the  syringe  removed,  the  cannula  being  left  in 
place  for  further  injection  if  necessary. 

In  this  way  the  anesthetic  solution  is  distributed  through  the 
tissues  between  the  two  tourniquets  and  is  brought  in  contact  with 
the  nerve  trunks  and  nerve  endings  of  the  whole  area.     Direct  anes- 

FiG.  72. — Bier's  venous  anesthesia.     Showing  the  application  of  the  bandages  and 

the  site  of  injection -|-. 

thesia  follows  between  the  bandages  in  three  to  five  minutes,  and 
indirect  anesthesia  beyond  the  distal  bandage  is  observed  in  six  to 
twenty  minutes.  If  the  proximal  bandage  causes  pain,  as  is  some- 
times the  case,  a  second  one  may  now  be  placed  immediately  below  it 
on  the  anesthetized  area  and  the  first  one  may  be  removed.  As 
a  rule,  some  motor  paralysis  occurs  in  the  anesthetized  area,  but  it 
soon  disappears  after  removal  of  the  bandages.  Anesthesia  per- 
sists as  long  as  the  bandages  remain  in  place  and  rapidly  disap- 
pears after  their  removal,  so  it  is  absolutely  necessary  that  the  op- 
eration, including  hemostasis  and  suturing,  be  completed  before  the 
bandages  are  removed.  If  difiiculty  is  experienced  in  recognizing 
cut  vessels,  sahne  may  be  injected  into  the  cannula  and  it  will  spurt 
from  the  open  ends.  The  danger  of  poisoning  from  absorption  of 
the  drug  employed  for  anesthesia  may  be  disregarded.     This  appar- 

1  Bier  in  a  later  communication  {Edinburg  Medical  Journal,  Aug.,  19 10)  states 
that  the  injection  may  also  be  made  centrally,  opening  the  vein  close  to  the  distal 


ent  danger  was  formerly  guarded  against  by  washing  out  the  veins 
with  saHne  at  the  end  of  the  operation.  This  precaution  is  now 
regarded  as  unnecessary,  for,  according  to  Bier,  the  anesthetic 
quickly  goes  through  the  vein  wall  and  the  greater  portion  of  it 
becomes  bound  up  in  the  tissues,  returning  to  the  circulation  very 

Variations  in  Technic. — Following  Bier's  lead,  others  have 
injected  local  anesthetics  into  the  arterial  system  instead  of  into  a 
vein.  Thus  Goyanes  (quoted  in  Centralhlatt  fur  Chirurgie,  1909, 
Vol.  XXVI)  describes  a  method  of  regional  anesthesia  by  the  injec- 
tion of  the  anesthetic  solution  into  an  artery.  Two  to  3  ounces  (50 
to  100  c.c.)  of  a  0.5  per  cent,  solution  of  novocain  in  normal  salt 
solution,  colored  with  a  few  drops  of  concentrated  methylene  blue  solu- 
tion so  that  the  operator  may  note  the  penetration  of  the  tissues  by 
the  anesthetic,  are  slowly  injected  by  means  of  define  needle  inserted 
obMquely  into  the  vessel  between  Esmarch  bandages  in  a  manner  very 
similar  to  the  method  of  Bier. 

Ransohoff  {Annals  of  Surgery,  April,  1910)  describes  a  method  of 
terminal  arterial  anesthesia  obtained  by  injecting  cocain  solution  into 
an  artery  supplying  the  area  of  operation.  He  reports  two  cases  in 
which  the  method  was  employed,  as  well  as  a  number  of  experiments 
upon  animals  which  would  seem  to  show  that  it  is  a  safe  and  efficient 
procedure  in  suitable  cases.  He  recommends  this  method  as  being 
especially  applicable  to  operations  upon  the  upper  extremity  where 
the  brachial,  ulnar,  or  radial  artery  may  be  exposed  without  difficulty 
and  in  operations  upon  the  foot  or  ankle  after  exposure  of  the  anterior 
tibial  artery. 

Ransohoff 's  technic  is  as  follows:  "The  main  artery  supplying 
the  part  to  be  anesthetized  is  exposed  under  infiltration  anesthesia. 
An  Esmarch  strap  is  now  bound  about  the  limb  some  distance 
above  the  point  of  proposed  injection  into  the  artery.  The  Esmarch 
should  be  used  as  in  the  Bier  hyperemic  treatment;  that  is,  snug 
enough  to  constrict  the  veins,  but  not  so  tight  as  to  interfere  with  the 
arterial  circulation.  From  4  to  8  c.c.  (i  to  2  dr.)  of  a  0.5  per  cent, 
solution  of  cocain  in  normal  salt  solution  should  be  injected  into  the 
artery  in  the  direction  of  the  blood  stream.  The  needle  used  should 
be  as  fine  as  possible.  After  anesthesia  is  complete,  the  Esmarch  may 
be  tightened  if  perfect  hemostasis  is  desired." 

It  is  claimed  that  the  cocain  thus  introduced  is  carried  by  the 
capillaries  to  the  individual  nerve  endings  and  the  solution  is  diffused 
through  the  capillary  walls  into  the  surrounding  tissues  so  that  little, 


if  any,  solution  is  returned  to  the  general  circulation.     The  writer 
has  had  no  experience  with  the  arterial  method. 


This  form  of  anesthesia  is  produced  by  injecting  weak  solutions  of 
drugs  having  local  analgesic  properties  into  the  subarachnoid  space. 
Cocainization  of  the  spinal  cord  was  first  suggested  by  Corning  in 
1885.  Bier,  in  1899.  improved  upon  the  method  and  made  it  prac- 
ticable for  surgical  purposes. 

The  enthusiasm  with  which  spinal  anesthesia  was  first  received 
has,  however,  proved  unwarranted  by  practical  results.  The  mor- 
tality is  higher  than  from  ether  or  chloroform,  and  it  is  not  absolutely 
certain  that  permanent  harm  to  the  cord  may  not  result.  Certainly, 
cases  have  been  reported  which  would  suggest  such  a  possibility.  In 
a  certain  percentage  of  the  cases  anesthesia  does  not  develop  or  is 
incomplete,  and  at  times  most  unpleasant  symptoms  accompany 
the  anesthesia;  headache,  nausea,  vomiting,  sweating,  chills,  rise  of 
temperature,  or  collapse  are  by  no  means  rare.  Spinal  anesthesia  has 
a  place  in  surgery,  without  doubt,  but  it  should  be  reserved  for  those 
exceptional  cases  in  which  general  anesthesia  is  contraindicated 
or  other  methods  of  local  anesthesia  are  impracticable.  Recent 
syphilitic  infections,  diseases  of  the  brain  and  spinal  cord,  marked 
curvature  of  the  spine,  and  cases  of  general  septicemia  are  contra- 
indications to  spinal  anesthesia. 

Injections  have  been  made  in  all  portions  of  the  cord,  but  for 
practical  surgical  purposes  they  are  now  limited  to  the  lumbar  region. 
The  danger  of  inducing  respiratory  paralysis  is  too  great  to  warrant 
the  introduction  of  analgesics  into  the  higher  regions  of  the  cord.^ 

Solutions  Used. — All  the  various  local  anesthetics  have  been  used, 
but  at  the  present  time  stovain  and  tropacocain  are  the  drugs  most 
frequently  employed  for  spinal  anesthesia. 

Cocain  is  now  generally  discarded  for  some  of  the  less  dangerous 
substitutes.  If  employed,  it  may  be  used  in  a  2  per  cent,  solution  in 
normal  salt  solution,  10  to  4oTrL  (0.6  to  2.5  c.c.)  of  such  a  solution, 
containing  between  1/5  and  i  gr.  (0.01296  and  0.065  gm.)  of  cocain, 
are  injected.  The  addition  of  a  few  drops  of  a  i  to  1000  solution  of 
adrenahn  chlorid  to  the  cocain  is  said  to  be  of  great  benefit,  prevent- 
ing the  rapid  difi'usion  of  the  anesthetic,  and  many  of  the  impleasant 

Stovain  is  less  toxic  than  cocain  and  is  very  highly  recommended 


by  many  authorities.  A  5  per  cent,  solution  is  used,  the  dose  being 
3/4  to  I  gr.  (0.0486  to  0.065  gm.). 

Novocain  is  also  frequently  employed.  It  is  about  seven  times 
less  poisonous  than  cocain.  A  5  per  cent,  solution  in  normal  salt 
solution  is  employed.  The  ordinary  dose  is  from  3/4  to  i  1/2  gr. 
(0.0486  to  0.0974  gm.). 

Tropacocain  is  another  substitute  for  cocain  frequently  used,  and 
the  anesthesia  is  more  lasting.  It  is  given  in  a  dose  of  from  1/2  to 
I  gr.  (0.0324  to  0.065  gm.)  in  a  5  per  cent,  solution. 

At  the  present  time  many  operators  employ  solutions  with  a  higher 
or  a  lower  specific  gravity  than  the  cerebrospinal  fluid,  so  that  when 
the  solution  is  injected  it  will  either  fall  or  rise.  To  render  the  solu- 
tion lighter  or  more  diffusible  alcohol  is  added.  Babcock  (/.  A .  M.  A., 
Oct.  II,  19 13)  gives  the  following  formulas  for  light  solutions: 

A.  Stovain, 
Lactic  acid, 
Absolute  alcohol, 
Distilled  water, 

B.  Tropacocain, 
Absolute  alcohol, 
Distilled  water, 

C.  Novocain, 
Absolute  alcohol, 
Distilled  water. 

One  to  1.5  c.c.  (16  to  25  minims)  of  these  mixtures  is  given  as  the  adult  dose. 

Barker  employs  the  following  solution: 

Stovain,  five  parts 

Glucose,  five  parts 

Distilled  water,  ninety  parts  (all  by  weight). 

This  solution  is  heavier  than  the  cerebrospinal  fluid,  having  a 
specific  gravity  of  1023  against  1007  for  the  cerebrospinal  fluid,  and 
sinks  to  the  lowest  level  of  the  canal.  It  is,  therefore,  possible  to 
obtain  an  anesthesia  at  any  level  by  adjusting  the  patient's  position 
by  the  aid  of  pillows  so  that  the  desired  vertebra  lies  at  the  lowest 

The  injection  of  a  solution  of  Epsom  salt  has  been  advocated  by 
Meltzer,  Haubold,  and  others.  Sixteen  minims  (i  c.c.)  of  a  25  per 
cent,  solution  are  given  for  every  25  pounds  (10  K.)  of  body  weight. 
Three  to  four  hours  after  the  injection  paralysis  and  analgesia  in  the 


0.08  gm. 

I  1/4  gr- 

0.04  c.c. 

2/3  gr- 

0.  2  c.c. 

3  minims 

1.8  c.c. 

30  minims 

0. 1  gm. 

I  1/2  gr. 

0.2   c.c. 

3  minims 

1.8  c.c. 

30  minims 

0. 16  gm. 

2  1/2  gr. 

0.  2  c.c. 

3  minims 

1.8  c.c. 

30  minims 



legs  and  pelvic  regions  appear  and  persist  for  from  eight  to  fourteen 
hours.  It  is  claimed  that  ov^erdosage  endangers  life  from  respiratory 

Apparatus. — A  special  stylet  needle  and  an  appropriate  syringe 
with  a  capacity  of  about  i  1/4  drams  (5  c.c.)  should beprovided.  The 
needle  should  be  of  platinum  or  nickel,  1/25  inch  (i  mm.)  in 
diameter,  and  about  3  3/4  inches  (9.5  cm.)  long.  The  stylet  must  be 
ground  to  a  point  with  the  needle  and  should  fit  the  latter  accurately 
at  the  point,  to  avoid  carrying  in  fragments  of  tissue  as  it  traverses 
the  flesh.  It  is  important  that  the  point  of  the  needle  be  not  too 
long — the  more  transversely  it  is  ground  the  better.  With  a  short- 
pointed  needle  the  liability  of  injecting  only  a  portion  of  the  solution 

Fig.  73. — Apparatus  for  spinal  anesthesia,  i,  Ethyl  chlorid;  2,  medicine 
glasses,  one  for  receiving  the  spinal  fluid  and  the  other  for  the  anesthetic  solution ; 
3,  ampule  containing  the  anesthetic;  4,  scalpel;  5,  syringe  and  trocar. 

into  the  canal  and  part  outside  the  subarachnoid  space  is  quite  remote. 
In  addition,  a  scalpel  for  making  the  preliminary  puncture  and  ster- 
ilized medicine  glasses  for  holding  the  solution  to  be  injected  should  be 
provided  (Fig.  73). 

Location  of  the  Puncture. — Any  of  the  spaces  between  the  second 
lumbar  and  the  first  sacral  vertebra  is  available  for  the  puncture,  but 
the  usual  site  is  between  the  third  and  fourth,  or  the  fourth  and 
fifth  lumbar  vertebra  (Fig.  74).  The  spaces  may  be  identified  by 
counting  down  from  the  seventh  cervical  vertebra.  If  this  is  difficult 
on  account  of  excess  of  fat,  the  fourth  lumbar  spinous  process  may  be 
readily  located,  and  from  it  the  other  vertebrae,  by  passing  a  line 
between  the  highest  points  of  the  iliac  crests.  Such  a  line  passes 
through  the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra 



(Fig.  75).  Puncture  in  the  mid-line  is  generally  practised,  as  it 
insures  the  solution  being  more  evenly  distributed  on  both  sides  of 
the  cord  and  lessens  the  chance  of  a  one-sided  analgesia.     A  point 

Fig.  74. — Points  for  injecting  the  anesthetic  solution  in  spinal  anesthesia. 

between  the  two  spines  in  the  mid-line  is  chosen,  and  starting  from 
this  point  the  needle  is  passed  slightly  upward  and  forward  between 
the  spinous  processes.     The  average  space  available  for  the  puncture 

Fig.  75. — Showing  the  method  of  locating  the  fourth  spinous  process  by  passing  a 
line  through  the  highest  points  of  the  iliac  crests. 

between  the  bones  in  the  lumbar  portion  of  the  cord  is  18/25  to  4/5 
inch  (18  to  20  mm.)  in  the  transverse,  and  2/5  to  3/5  inch  (10  to 
15  mm.)  in  the  vertical  diameter. 



Asepsis. — The  operation  should  be  performed  with  the  greatest 
aseptic  care.  The  needle  and  syringe  should  always  be  boiled  in 
plain  water,  the  solution  injected  must  be  sterile,  and  the  operator's 
hands  and  site  of  ooeration  should  be  prepared  with  all  the  care  that 
would  be  observed  in  any  operation. 

Fig.  76. — Sitting  position  for  spinal  puncture. 

Preparation  of  the  Patient. — This  should  be  the  same  as  for  an 
operation  under  general  anesthesia  (see  page  2).  If  the  operation 
is  to  be  a  prolonged  one,  morphin  gr.  1/4  (0.0162  gm.)  should  be 
given  hypodermically  half  an  hour  beforehand. 

Fig.  77. — Lateral  position  for  spinal  puncture. 

Position  of  the  Patient. — The  body  of  the  patient  is  curved  well 
forward  so  as  to  widen  the  intervertebral  spaces  as  much  as  possible. 
For  this  purpose  the  patient  sits  up,  leaning  well  forward,  with  his 
back  to  the  operator  (Fig.  76),  or  else  lies  upon  one  side  with  the 
back  in  the  form  of  an  arch  (Fig.  77). 



Technic. — The  spot  chosen  for  the  puncture  is  anesthetized  with 
ethyl  chlorid  or  by  infiltration  with  a  few  drops  of  cocain,  and  a  small 
puncture  is  made  in  the  skin  with  a  scalpel  (Fig.  78),  to  lessen  the 
danger  of  carrying  in  infection  with  the  needle.  The  operator  then 
identifies  with  his  finger  a  point  in  the  mid-line  between  the  two  spi- 
nous processes  bounding  the  space  for  the  puncture,  and  inserts  the 
needle  armed  with  its  stylet  in  a  slightly  upward  and  forward  direc- 
tion until  it  enters  the  subarachnoid  space  (Fig.  79).  Lessened  resist- 
ance, followed  by  the  escape  of  the  fluid  from  the  needle,  determines 
when  this  is  accomplished.  The  distance  necessary  to  be  traversed 
varies  from  i  to  i  1/2  inches  (2.5  to  4  cm.)  in  a  child,  2  1/2  to  3  inches 

Fig.  78. 
Pig.  78. — Spinal  anesthesia. 
Fig.  79. — Spinal  anesthesia. 

Fig.  79. 
First  step,  nicking  the  skin  at  the  site  of  puncture. 
Second  step,  inserting  the  needle. 

(6  to  7.5  cm.)  in  an  adult.  In  inserting  the  needle,  if  it  strikes  bone,  it 
should  be  withdrawn  slightly  and  its  direction  changed.  The  cere- 
brospinal fluid  should  gush  out  with  some  force  on  removal  of  the 
stylet  and  should  be  clear.  If  only  a  few  drops  escape  or  the  fluid  is 
reddish  in  color  it  indicates  that  the  needle  is  not  properly  inserted, 
and  a  new  puncture  should  be  made.  A  quantity  of  cerebrospinal 
fluid,  corresponding  to  the  amount  of  anesthetic  to  be  injected,  should 
be  allowed  to  escape  before  the  analgesic  solution  is  introduced  (Fig. 
81).  This  will  vary  from  10  to  4oTn,  (0.6  to  2.5  c.c),  according  to 
the  strength  of  the  solution  to  be  used.  As  soon  as  the  desired 
quantity  of  cerebrospinal  fluid  has  escaped,  the  flow  is  stopped  by 



placing  a  finger  over  the  end  of  the  needle,  and  the  syringe,  filled 
with  the  proper  amount  of  solution,  is  attached.  Some  operators 
prefer  to  dissolve  the  analgesic  agent  in  the  cerebrospinal  fluid  with- 

FlG.  80. — Showing  the  direction  of  the  needle  in  entering  the  spinal  canal. 

Fig.  81.  Fig.  82. 

Fig. '8 1. —Spinal  anesthesia.  Third  step,  allowing  the  cerebrospinal  fluid  to 

Fig.  82. — Spinal  anesthesia.  Fourth  step,  injecting  the  anesthetic  solution. 

drawn  and  reinject  the  solution  thus  formed.  The  solution  should 
always  be  slowly  introduced  (Fig.  82).  The  needle  is  then  with- 
drawn  and   the  puncture  sealed  with  collodion  and  cotton,  or  is 


dressed  with  a  piece  of  gauze  held  in  place  by  adhesive  plaster.  If  a 
heavy  solution  is  employed  and  the  operator  desires  a  low  anesthesia 
only,  the  patient  is  kept  in  the  upright  position  for  a  few  moments 
after  the  injection  to  allow  the  solution  to  gravitate  downward,  but, 
if  a  light  solution  is  used,  the  patient's  head  must  be  immediately 
lowered  to  prevent  its  rapid  spread  upward. 

As  the  solution  comes  in  contact  with  the  nerve  roots  it  blocks 
their  conductivity,  and  in  from  ten  to  fifteen  minutes  loss  of  sensation, 
often  accompanied  by  muscular  paralysis,  takes  place.  The  anesthe- 
sia becomes  marked  first  in  the  anal  and  perineal  regions,  and  then  in 
the  lower  extremities,  being  limited  above,as  a  rule,  to  a  zone  not  higher 
than  the  waist  line.  With  a  successful  injection,  any  operation  about 
the  lower  extremities,  the  anus,  perineum,  or  pelvis  may  be  readily 
performed.  The  anesthesia  thus  obtained  persists  for  two  hours  or 

Following  the  operation  the  patient  is  kept  recumbent  in  bed  with 
the  upper  part  of  his  body  slightly  raised  and  is  not  permitted  to  sit 
upright  for  twenty-four  hours. 

Sacral  Anesthesia. — The  idea  of  anesthetizing  the  sacral  nerves 
by  injecting  drugs  into  the  extra-dural  space  through  the  lower  end 
of  the  sacral  canal  originated  with  Cathelin.  Later  the  method  was 
employed  in  obstetrics  for  the  purpose  of  obtaining  painless  deliver- 
ies, but  it  never  came  into  general  use.  More  recently  sacral  anes- 
thesia has  been  revived  and  the  technic  improved  by  Lawen  and 
others  to  such  an  extent  that  the  method  is  now  of  recognized  value  in 
operations  upon  the  genital  and  anal  regions  below  the  level  of  the 
fifth  lumbar  nerve. 

Like  spinal  anesthesia,  the  sacral  method  fails  in  a  certain  propor- 
tion of  cases  even  in  the  hands  of  those  skilled  in  its  use,  and  in  some 
cases  only  partial  anesthesia  is  obtained.  Most  of  the  failures  are 
met  with  in  very  stout  individuals.  In  a  successful  case  the  anes- 
thesia usually  lasts  for  from  3/4  to  an  hour.  The  anesthesia  is 
not  accompanied  by  unpleasant  symptoms,  such  as  headache  and 
vomiting,  that  are  sometimes  observed  in  spinal  anesthesia,  though 
a  transient  pallor,  acceleration  of  the  pulse,  and  a  fall  in  blood- 
pressure  may  occur. 

Anatomy. — Upon  the  dorsal  surface  of  the  sacrum  in  the  median 
line  may  be  recognized  the  spinous  processes  of  the  three  or  four  upper 
vertebras,  the  fourth  spine  sometimes,  and  the  fifth  spine  always  being 
absent  through  failure  of  the  lamina  to  coalesce.  A  triangular  gap, 
known  as  the  hiatus  sacralis,  is  thus  formed  through  which  a  needle 



may  be  readily  passed  into  the  sacral  canal.  The  lower  margins  of 
this  opening  are  prolonged  downward  as  two  tubercles,  the  sacral 
cornua  (Fig.  83). 

^acraJ  canal 

Sacra.1  cornu 

Fig.  83. — The  posterior  surface  of  the  sacrum,  showing  the  hiatus  sacralis. 

The  sacral  canal  contains  the  lower  end  of  the  cauda  equina,  the 
lilum  terminale,  and  the  spinal  dura.  The  latter  extends  to  the  level 
of  the  second  sacral  vertebra  or  to  within  21/2  inches  (6  cm.)  of  the 
hiatus  (Fig.  84). 

fllum  termmelt 

Fig.  84. — Showing  the  interior  of  the  sacral  canal. 

Instruments. — The  instruments  required  are  the  same  as  for 
spinal  anesthesia  (page  100),  except  a  larger  syringe — one  with  a 
capacity  of  about  5  drams  (20  c.c.) — will  be  found  preferable. 


Solutions  Used. — Cocain,  novocain,  and  quinin  and  urea  have  all 
been  used  for  sacral  anesthesia,  but  novocain  is  the  drug  generally 
employed.  It  is  claimed  that  the  addition  of  sodium  bicarbonate  to 
the  novocain  solution  adds  to  the  anesthetic  effect.  The  solution  is 
made  up  as  follows: 

Sodium  bicarb,  puriss.,  0.25  gm.  (3  3/4  gr.) 

Sodium  chlorid,  0.5  gm.  (8  gr.) 

Novocain,  i  gm.  (15  gr.) 

This  is  dissolved  in  100  c.c.  (3  1/3  ounces)  of  cold  sterile  distilled 
water,  and  is  sterilized  by  boiling.  When  it  has  cooled,  5  drops  of  a 
I  to  1000  adrenalin  chlorid  solution  are  added.  The  quantity  of 
novocain  used  at  a  dose  is  from  0.4  to  0.6  gm.  (6  to  9  gr.). 

Asepsis. — The  instruments  are  sterilized  by  boiling  in  plain  water, 
the  solution  is  boiled,  and  the  operator's  hands  are  cleansed  as  for 
any  operation.  The  patient's  skin  at  the  site  of  proposed  puncture 
is  painted  with  tincture  of  iodin. 

Site  of  Puncture. — The  puncture  is  made  in  the  median  line 
through  the  lower  end  of  the  sacral  canal.  The  opening  is  identified 
by  palpating  the  spinous  processes  of  the  sacrum  downward  until  it 
is  felt  that  they  divide  in  a  fork-like  manner,  forming  the  boundaries 
of  a  triangular  area,  the  hiatus. 

Position  of  Patient. — The  patient  should  be  in  the  Sims  position. 

Preparation  of  Patient. — The  patient  is  given  by  hypodermic  half 
an  hour  before  the  operation  morphin  gr.  1/6  (0.0108  gm.)  and  atro- 
pin  gr.  i/ioo  (0.00065  g^i-)-  To  this  may  be  added  scopolamin 
gr.  i/ioo  (0.00065  gm.),  if  the  operation  is  especially  difficult  or 

Technic. — The  point  of  proposed  puncture  is  located  and  the 
skin  is  infiltrated  with  a  0.2  per  cent,  solution  of  cocain  or  a  i  per 
cent,  solution  of  novocain.  A  small  nick  is  then  made  in  the  skin, 
and  the  needle,  with  the  trocar  in  place,  is  inserted  at  an  angle  of 
about  45  degrees  until  it  strikes  the  bone  forming  the  anterior  wall  of 
the  canal  (Fig.  85).  The  trocar  is  then  withdrawn,  and  the  direction 
of  the  needle  is  changed  to  correspond  with  the  direction  of  the  sacral 
canal.  It  is  then  pushed  into  the  canal  for  a  distance  of  about  an 
inch  (2.5  cm.).  If  the  needle  is  in  the  canal  its  point  may  be  freely 
moved  about,  and,  upon  making  a  test  injection  with  normal  salt 
solution,  the  solution  can  be  injected  with  ease.  If  difficulty  is  met 
in  inserting  the  needle,  the  sacral  opening  may  be  first  exposed  by 
an  incision  under  infiltration  anesthesia  as  recommended  by  Lynch. 



A  little  blood  may  flow  from  the  needle,  due  to  injury  to  some 
small  veins,  and  may  be  disregarded,  but,  if  the  bleeding  is  profuse, 
or  if  blood  escapes  in  spurts,  the  injection  should  be  abandoned; 
the  same  is  true  if  clear  fluid  escapes  from  the  needle  indicating  that 
the  dura  has  been  punctured.     The  anesthetic  solution  should  be 

Fig.  85. — Direction  taken  by  the  needle  in  entering  the  sacral  canal. 

injected  very  slowly,  and,  when  the  desired  quantity  has  been  intro- 
duced, the  needle  is  removed  and  the  point  of  puncture  is  sealed  with 
collodion  and  cotton.  The  patient  is  then  brought  into  position  for 
operation,  and  in  from  3  to  5  minutes  the  anesthesia  is  complete. 


Sphygmomanometry  is  the  instrumental  estimation  of  arterial 
blood-pressure.  The  determination  of  blood-pressure  has  become  a 
subject  of  such  practical  importance  that  both  physicians  and  sur- 
geons should  be  familiar  with  the  technic.  In  certain  cases  it  is 
often  of  the  greatest  value  not  only  in  making  a  diagnosis,  but  for 
purposes  of  prognosis  and  as  a  guide  to  the  treatment.  It  is  es- 
pecially important  in  surgical  work  in  determining  the  fitness  of  a 
subject  for  anesthesia  (see  also  page  4)  and  during  an  operation 
in  revealing  impending  danger  from  shock  or  cardiac  weakness. 
For  the  latter  purposes  it  should  be  employed  as  a  routine  in  all 
serious  operations  likely  to  be  attended  by  shock  or  considerable 

In  studying  blood-pressure  two  measurements  are  made,  namely, 
the  systolic  and  the  diastolic  pressure,  and  from  these  readings  the 
pulse  pressure  and  the  mean  pressure  are  determined.  The  systolic 
pressure  is  the  maximum  pressure  caused  by  the  systole  of  the  heart; 
diastolic  pressure  is  the  minimum  pressure  in  the  artery.  The  pulse 
pressure  is  the  difference  between  the  systolic  and  the  diastolic  pres- 
sure; while  the  mean  pressure  is  the  arithmetic  mean  of  the  systolic 
and  diastolic  pressures;  for  example,  if  the  systolic  pressure  is  esti- 
mated at  145  mm.  and  the  diastolic  pressure  at  105  mm.,  the  mean 
pressure  would  be  125  mm. 

The  instrument  employed  for  estimating  blood-pressure  consists 
essentially  of  a  hollow  rubber  band  for  compression  of  an  artery,  con- 
nected with  a  manometer  and  inflating  bulb.  The  amount  of  pres- 
sure necessary  to  obliterate  the  pulse  distal  to  the  point  of  constric- 
tion measured  in  millimeters  of  mercury  represents  the  systolic  blood- 
pressure.  The  diastolic  pressure  is  obtained  by  gradually  releasing 
the  air  from  the  compression  band  after  the  pulse  has  been  obliterated 
and  noting  the  oscillations  of  the  column  of  mercury  in  the  manom- 
eter, the  base  line  of  the  greatest  oscillation  representing  the  dias- 
tolic pressure.  Both  systolic  and  diastolic  pressure  should  be  taken 
when  it  is  possible,  but  of  the  two  the  determination  of  the  systolic 



pressure  is  of  most  importance,  as  pathological  conditions  affect  it 
more  than  the  diastolic. 

The  average  normal  systolic  pressure  obtained  with  the  wide  (12 
cm.)  armlet,  according  to  Janeway,  is  as  follows: 

For  children  up  to  two  years,  75~QO  mm.  of  mercury 

For  children  over  two  years,  90-110  mm.  of  mercury 

For  adults,  100-130  mm.  of  mercury 

In  females  the  pressure  is  about  10  mm.  less  than  in  males.  After 
middle  life  the  pressure  generally  reads  higher — often  as  high  as  145 
mm.  A  systolic  pressure  between  145  and  90  mm.  in  an  adult  may, 
therefore,  be  considered  within  the  limits  of  health.  If,  on  repeated 
examinations,  the  pressure  registers  above  or  below  these  limits,  it 
should  be  viewed  with  suspicion.  A  pressure  above  200  mm.  is 
considered  very  high  and  below  70  mm.  very  low,  while  below  45  to 
40  mm.  the  pulse  can  rarely  be  recognized.  The  diastolic  pressure 
normally  registers  25  to  40  mm.  less  than  the  systolic.  If  the  differ- 
ence between  the  two  is  less  than  20  mm.  or  more  than  50  mm.,  it 
indicates,  in  the  first  instance,  an  abnormally  small  pulse,  and,  in  the 
latter  case,  an  abnormally  large  pulse. 

As  blood-pressure  is  dependent  upon  the  quantity  and  velocity  of 
the  blood  entering  the  circulation  with  the  contraction  of  the  left 
ventricle,  the  elasticity  of  the  arterial  walls,  the  volume  of  blood  in 
the  circulation,  and  on  the  resistance  in  the  peripheral  vessels,  it  can 
be  readily  seen  that  it  may  be  subject  to  considerable  variation  in 
health  and  may  be  modified  by  many  circumstances.  Anything 
which  increases  one  or  other  of  these  factors  will  raise  the  blood-pres- 
sure and  vice  versa.  Thus  a  recent  meal,  fear,  anxiety,  self-conscious- 
ness, mental  application,  pain,  drugs  which  act  upon  the  vascular 
system,  such  as  camphor,  caffein,  strychnin,  digitalis,  adrenalin,  etc., 
increase  blood-pressure.  Cold  causes  a  rise  in  blood-pressure  through 
its  constricting  effect  upon  the  peripheral  vessels;  warmth  has  the 
opposite  effect.  Smoking  likewise  increases  it  if  it  has  a  stimulating 
effect,  but  causes  it  to  fall  if  it  depresses.  Exercise  has  the  same 
effect,  that  is,  it  increases  pressure  unless  it  is  carried  to  exhaustion, 
when  the  pressure  falls.  The  posture  of  the  individual  also  modifies 
the  pressure  reading,  it  being  10  to  15  mm.  higher  with  the  person 
standing  than  when  lying  down.  Likewise,  the  pressure  is  generally 
higher  in  the  afternoon.  The  size  of  the  encircling  band  is  also  impor- 
tant, the  narrow  bands  giving  a  higher  reading  than  the  broad  ones. 
Furthermore,  as  the  estimation  of  pressure  depends  on  the  tactile 



sense  of  the  individual  palpating  the  pulse,  the  pressure  readings  in  the 
same  patient  will  vary  somewhat  with  different  observers.  There- 
fore, to  avoid  these  sources  of  error  and  obtain  readings  of  value  for 
comparison,  the  determination  of  pressure  should  always  be  made  by 
the  same  observer,  under  the  same  conditions,  at  the  same  time  of  day, 
with  the  patient  in  the  same  position,  and  at  rest  mentally  and 
physically,  and  employing  the  same  size  armlet. 

Instruments. — There  have  been  a  number  of  excellent  sphyg- 
momanometers devised,  such  as  the  Riva-Rocci,  Stanton,  Erlanger, 
Janeway,  Hill  and  Barnard,  Faught,  Rogers,  etc.  A  few  of  these  will 
be  described. 

Fig.  86. — The  Riva-Rocci  Sphygmomanometer. 

The  Riva-Rocci  sphygmomanometer  (Fig.  86),  as  modified  by 
Cook,  consists  of  a  portable  manometer  with  a  jointed  tube  and  scale 
reading  up  to  320  mm.  The  armlet  consists  of  a  rubber  bag  4  1/2 
inches  (11.5  cm.)  wide  by  16  inches  (40  cm.)  long,  covered  with  can- 
vas, and  suppHed  with  hooks  and  eyes  for  fastening  it  in  place.  A 
Richardson  double  inflating  bulb  is  connected  with  the  armlet,  and 
also  with  the  manometer  by  means  of  a  glass  T-tube  and  rubber  tub- 
ing. A  second  glass  T-tube  is  inserted  in  the  rubber  tubing  near  the 
manometer,  to  the  long  arm  of  which  is  attached  a  short  rubber  tube 
supplied  with  a  pinchcock,  for  the  purpose  of  releasing  the  pressure. 



Fig.  87. — Stanton's  Sphygmomanometer. 

Fig.  88. — Janeway's  Sphygmomanometer. 



Stanton's  instrument  (Fig.  87)  consists  of  a  rubber  compression 
armlet  4  1/2  inches  (11.5  cm.)  wide  by  16  inches  (40  cm.)  long, 
inclosed  in  a  cuff  of  leather  or  thick  canvas  reinforced  by  tin  strips. 
In  the  center  of  the  cuff  is  cemented  a  glass  tube  1/4  inch  (6  mm.) 
in  diameter.  The  manometer  consists  of  a  metal  cistern  connected 
by  a  metal  tube  with  a  glass  mercury  tube  having  a  scale  registering 
to  300  mm.  The  metal  cistern  is  provided  with  a  screw  cap  having  a 
T-shaped  metal  tube,  one  arm  of  which  is  connected  with  the  armlet 
and  the  other  with  the  inflating  apparatus,  which  consists  of  a  double 
inflating  bulb.  At  the  top  of  the  metal  cistern  is  a  screw  valve  for 
the  gradual  release  of  pressure,  and  on  the  arm  connected  with  the 
inflating  apparatus  is  a  stopcock  to  shut  off  the  inflation. 

Janeway's  instrument  (Fig.  88)  consists  of  a  U-shaped  manometer 
with  a  sliding  scale,  connected  with  a  cistern,  to  one  side  of  which  is 
attached  the  armlet  and  to  the  other  a  Politzer  bag  for  the  purpose  of 

— Rogers'  Sphygmomanometer. 

inflation.  The  armlet  is  a  closed  rubber  bag  measuring  4  3/4  inches 
(12  cm.)  in  width  and  18  inches  (45  cm.)  in  length,  inclosed  in  a 
leather  cuff  that  is  fastened  to  the  limb  by  means  of  two  straps.  A 
stopcock  containing  a  needle  valve  for  the  release  of  pressure  is  inter- 
posed between  the  cistern  and  inflating  bag.  The  instrument  is 
unassembled  for  packing  in  its  case  as  follows:  The  scale  is  sHd  down 
and  the  upper  part  of  the  manometer  is  removed  and  placed  in  rings 
provided  for  this  purpose  on  the  lid.  The  open  end  of  the  manometer 
is  plugged  by  a  small  cork  "A"  and  the  other  end  is  closed  automatic- 
ally when  the  lid  is  shut  by  a  block  which  compresses  the  rubber 
"B."  The  inflation  bulb  is  removed,  and,  as  the  box  shuts,  the  stop- 
cock slips  under  a  spring  "C." 

Rogers'  Sphygmomanometer  (Fig.  89)  registers  blood-pressure 
by  means  of  an  aneroid  scale.  The  instrument  consists  of  a  rubber 
armlet  connected  by  two  tubes  with  a  gage  and  an  inflating  bulb. 



The  dial  registers  from  o  to  260  mm.  of  mercury.  Upon  the  tube 
leading  from  the  inflating  bulb  is  placed  a  valve  for  releasing  the  air 
from  the  armlet.  The  readings  obtained  by  this  instrument  corre- 
spond very  closely  to  the  figures  obtained  with  the  mercury  instru- 
ments, and  the  instrument  has  an  advantage  over  the  latter  in  its 
simplicity  and  ease  of  operation. 

Whatever  form  of  instrument  is  employed,  a  wide  armlet  (4  1/2  to 
4  3/4  inches  (11.5  to  12  cm.))  should  be  used. 

Site  of  Application. — The  compression  band  may  be  applied  to  the 
arm  or  the  thigh,  the  former  being  preferable. 

Position  of  Patient. — The  patient  should  be  recumbent  with  the 
part  subjected  to  pressure  on  a  level  with  the  heart, 

Technic  {Riva-Rocci  Instrument). — The  armlet  is  fastened  about 
the  arm  midway^ between  the  shoulder  and  elbow  by  passing  the  open 
end  of  the  cuff  beneath  the  band  on  the  closed  end  and  hooking  it  in 
place.  The  manometer  is  placed  upon  a  table  near  by,  and  care  is 
taken  to  see  that  the  upper  portion  of  the  mercury  tube  is  fitted 
securely  in  the  top  of  the  lower  one  and  that  the  mercury  is  at  the  zero 
point.  The  inflating  bulb  is  then  properly  connected  with  the  arm- 
let and  manometer,  and  the  pinchcock  is  closed.  The  examiner, 
with  the  fingers  of  one  hand  palpating  the  patient's  pulse,  gradually 
inflates  the  armlet  by  squeezing  the  bulb  with  the  other  hand  until 
the  pressure  obliterates  the  pulse,  when  the  height  of  the  mercury  is 
noted.  The  mercury  is  then  allowed  to  drop  slowly  until  the  pulse 
just  reappears  which  represents  the  systolic  pressure.  For  the  sake 
of  greater  accuracy,  this  maneuver  is  repeated  by  squeezing  and  relax- 
ing the  reservoir  bulb. 

Stanton's  Instrument. — The  armlet  is  buckled  in  place  and  is  con- 
nected with  the  manometer,  the  scale  of  which  is  adjusted  so  that  the 
mercury  registers  zero.  With  the  valve  "B"  closed  and  cock  "A" 
open,  and  with  the  lingers  of  the  operator  on  the  patient's  pulse,  the 
armlet  is  slowly  inflated  until  the  pressure  causes  the  pulse  to  dis- 
appear. The  inflation  cock  "A"  is  then  closed  and  valve  "B"  is 
gradually  opened  until  the  pulse  just  reappears.  The  height  of  the 
mercury  when  this  occurs  represents  the  systoKc  pressure.  The  pres- 
sure is  further  slowly  reduced  a  few  millimeters  at  a  time,  and,  as  the 
mercury  falls,  its  column  oscillates  up  and  down,  increasing  in  size 
until  a  maximum  is  reached  and  then  diminishing.  The  base-line  of 
the  maximum  oscillations  represents  the  diastoKc  pressure,  which  is 
normally  25  to  40  mm.  below  the  systolic  pressure. 

Janeway^s  Instrument. — The  armlet  is  properly  secured  about  the 



limb  as  described  above  and  the  scale  is  so  adjusted  that  the  level  of 
the  two  columns  of  mercury  is  at  zero.  With  the  fingers  on  the  radial 
pulse  the  armlet  is  gradually  inflated  by  compressing  the  bulb 
until  the  pulse  disappears.  Then,  by  slowly  releasing  the  bulb  until 
the  pulse  just  returns,  the  systolic  pressure  is  estimated.  In  cases  of 
very  high  pressure,  it  may  be  necessary  to  employ  more  than  one  bulb 
full  of  air  to  obliterate  the  pulse.  In  such  a  case,  the  stopcock  is 
closed,  and,  after  the  bag  is  refilled,  the  cock  is  opened  again  and  the 
pressure  raised  as  high  as  desired.  The  diastolic  pressure  is  obtained 
in  the  same  manner  as  described  under  the  technic  with  the  Stanton 

Fig.  90. — Technic  of  sphygmomanometry  with  the  Stanton  instrument. 

Rogers^  Instrument. — The  compression  band  is  applied  about  the 
arm  like  a  bandage  and  is  secured  by  slipping  the  free  end  under  the 
last  turn.  The  aneroid  gage  is  hung  from  a  hook  on  the  outer  aspect 
of  the  armlet  and  the  gage  and  inflating  bulb  are  properly  connected. 
To  measure  the  systolic  pressure  the  cuff  is  inflated  until  the  radial 
pulse  is  obliterated,  and  the  pressure  in  the  cuff  is  raised  i  to  2  mm. 
higher.  Air  is  then  allowed  to  escape  slowly  from  the  armlet  until 
the  radial  pulse  beats  just  reappear.  The  figure  on  the  dial  at  which 
the  hand  points  at  this  moment  represents  the  systolic  pressure.  The 
diastolic  pressure  is  obtained  by  allowing  air  to  escape  from  the  arm- 
let very  slowly  until  the  dial  shows  a  maximum  range  of  oscillations. 
The  valve  is  then  quickly  closed  and  the  minimum  oscillation  is 
taken  as  the  diastolic  pressure. 



The  Auscultatory  Method  of  determining  systolic  and  diastolic 
pressure  is  carried  out  by  the  aid  of  a  stethoscope  instead  of  by  pal- 
pation. The  cuff  is  applied  and  the  pulse  obliterated  in  the  usual 
way.  The  operator  then  places  a  stethoscope  over  the  brachial 
artery  below  the  cuff  and  listens  for  the  reappearance  of  the  first 
sound  (Fig.  91).  The  height  of  the  column  of  mercury  when  this 
occurs  represents  the  systolic  pressure.  If  the  armlet  be  further 
deflated  there  will  still  be  heard  murmurs  which  rapidly  disappear 
when  the  mercury  drops  30  to  45  mm.  below  the  systolic  reading. 
The  point  at  w^hich  all  sounds  disappear  represents  the  diastoHc 

Pig.  91. — Sphygmomanometer  by  the  auscultatory  method. 

With  this  method  the  systolic  pressure  is  recorded  at  a  slightly 
higher  and  the  diastolic  pressure  at  a  lower  reading  than  by  the  pal- 
pation method,  and  as  a  result  the  pulse  pressure  will  be  also  higher. 

Variations  of  Blood-pressure  in  Disease.^ — Pain  of  all  kinds 
causes  an  increase  in  the  peripheral  resistance,  and  a  rise  in  pressure. 
Thus,  in  conditions  attended  with  severe  pain,  as  in  acute  biliary  or 
renal  colic,  during  labor,  in  acute  peritonitis,  etc.,  the  blood-pressure 
is  elevated.  If,  however,  the  patient  is  already  in  a  weakened  state  or 
is  suffering  from  shock,  the  addition  of  pain  may  cause  a  fall  in 

*  For  a  complete  exposition  of  this  phase  of  the  subject  the  reader  is  referred  to 
Janeway's  "Clinical  Study  of  Blood-pressure." 



Wasting  diseases,  or  cachetic  conditions,  as  cancer,  tuberculosis, 
etc.,  are  as  a  rule  accompanied  by  low  pressure.  In  tuberculosis,  if 
the  pressure  is  normal  or  increased,  it  is  looked  upon  as  a  good  prog- 
nostic sign. 

In  infectious  diseases  low  pressure  is  the  rule.  In  typhoid  fever  a 
rapid  drop  is  indicative  of  hemorrhage;  if  perforation  occurs,  there  is 
a  sudden  rise  in  pressure. 

Toxic  conditions,  such  as  lead  poisoning,  acute  gout,  uremia, 
eclampsia,  exophthalmic  goiter,  etc.,  are  accompanied  by  increased 
pressure  through  reflex  vasomotor  stimulation. 

Renal  Affections. — Acute  nephritis  may  or  may  not  produce  eleva- 
tion of  pressure.  The  same  is  true  of  chronic  parenchymatous  nephri- 
tis, but  in  the  chronic  interstitial  variety  high  pressure  is  the  rule.  In 
any  variety,  with  the  onset  of  uremic  symptoms,  the  blood -pressure 
rises,  but  falls  as  improvement  in  the  condition  sets  in. 

Cardiovascular  Diseases. — In  valvular  lesions  pressure  may  or 
may  not  be  elevated;  in  fact,  the  results  of  blood-pressure  observa- 
tions in  this  class  of  cases  are  too  varied  to  be  of  value.  In  primary 
myocarditis  the  blood-pressure  is  low,  but  when  secondary  to  arterial 
or  kidney  disease  it  may  be  high.  In  arteriosclerosis  the  pressure  is 
generally  elevated,  especially  with  hypertrophy  of  the  left  ventricle. 
Arteriosclerosis  may  exist,  however,  without  elevation  of  pressure, 
and,  if  cardiac  muscle  insufficiency  be  present,  the  pressure  may  be 
below  the  normal. 

Acute  Peritonitis. — In  the  early  stages,  the  pressure  is  abnormally 
high.  A  sharp  rise  may  precede  all  other  symptoms  in  the  beginning 
of  peritonitis  from  typhoid,  appendicular,  or  other  forms  of  perfora- 

Head  or  Brain  Injuries. — Blood-pressure  is  increased  in  compres- 
sion of  the  brain  from  depressed  bone,  extra-  or  subdural  clots,  ab- 
scess, tumors,  fracture  of  the  base,  apoplexy,  etc.,  in  proportion  to  the 
degree  of  intracranial  tension.  In  acute  compression  from  hemor- 
rhage a  high  and  rising  blood-pressure  indicates  an  increase  in  the 
bleeding  and  a  progressive  failure  of  the  circulation  in  the  medulla. 
When  the  paralytic  stage  of  compression  appears,  the  pressure  falls. 
Low  pressure  is  also  found  in  concussion  of  the  brain. 

Hemorrhage. — The  loss  of  considerable  blood  results  in  a  rapid   ' 
faU  of  pressure. 

In  shock  and  collapse  a  fall  in  blood-pressure  is  uniformly  present. 
According  to  Crile,  in  shock,  the  fall  in  pressure  is  gradual,  while  the 
term  "collapse"  should  be  limited  to  those  conditions  in  which  there 


is  a  sudden  fall  in  blood-pressure  due  to  hemorrhage,  injuries  of  the 
vasomotor  centers,  or  to  cardiac  failure. 

In  Surgical  Operations. — Ether  causes  a  rise  or  else  has  no  effect; 
even  in  large  quantities,  it  rarely  causes  a  fall.  Chloroform,  on  the 
other  hand,  causes  a  fall  in  pressure.  Nitrous  oxid  as  a  rule  causes 
an  increase  in  pressure. 

Superficial  cutting  operations  cause  a  rise  through  irritation  of  the 
peripheral  nerves — irritation  of  the  larger  nerve  trunks  causing  a 
greater  rise.  Opening  the  abdominal  cavity  likewise  produces  a  rise 
followed  by  a  fall,  the  degree  depending  upon  the  length  of  exposure 
of  the  viscera  to  the  air,  the  amount  of  handling,  separation  of  adhe- 
sions, and  sponging. 

Under  local  anesthesia  alterations  in  blood-pressure  are  less 
marked  than  when  the  same  procedures  are  carried  out  under  general 




The  term  transfusion,  as  commonly  used,  is  applied  to  the  trans- 
ference of  blood  from  the  vessels  of  a  healthy  individual  (the  donor) 
to  those  of  the  patient  (the  recipient),  while  the  term  infusion  is 
restricted  to  cases  in  which  other  media  than  blood  are  so  introduced. 

There  is  good  evidence  from  records  of  cases  that  transfusion  has 
been  practised  for  many  centuries,  but  it  was  not  until  Lower,  in 
1665,  and  Denys,  in  1667,  published  their  results  that  the  operation 
was  used  to  any  great  extent.  After  this,  it  was  employed  for  such  a 
variety  of  purposes  and  so  extravagant  were  the  claims  of  its  expo- 
nents that  the  French  government  prohibited  its  use,  and  it  soon  fell 
into  disrepute.  Early  in  the  nineteenth  century  the  operation  was 
revived,  and  it  became  a  recognized  means  of  supplying  the  body  with 
fluids  to  replace  that  lost  from  excessive  hemorrhage,  notably  that 
occurring  after  childbirth. 

The  transfusion  was  either  performed  directly  by  means  of  glass 
cannulas  tied  in  the  blood-vessels  and  joined  by  rubber  tubing,  or  else 
indirectly,  the  blood  being  drawn  from  the  donor,  and,  after  first  being 
defibrinated  by  whipping,  the  serum  resulting  was  injected  into  the 
veins  of  the  recipient.  Frequently  the  blood  of  dissimilar  species, 
such  as  sheep's  blood,  was  employed.  There  were  many  accidents 
resulting  from  the  use  of  alien  blood,  and  from  the  employment  of 
transfusion  in  an  improper  class  of  cases,  to  say  nothing  of  the  dangers 
of  infection  and  of  embolism  to  which  the  patient  was  exposed  by  the 
methods  used,  so  that  the  results  were  variable  and  uncertain,  and  in 
some  cases  even  fatal. 

As  the  subject  became  more  thoroughly  studied  and  better  under- 
stood, it  was  recognized  that  the  blood  of  dissimilar  species,  through 
its  faculty  for  breaking  up  the  red  blood-corpuscles,  was  impracticable 
and  dangerous  for  the  purpose  of  introduction  into  the  human  circu- 
lation, and  that  direct  transfusion  from  artery  to  vein  or  vein  to  vein 
only  was  permissible.^     Furthermore,  it  was  contended  by  many  that 

^  Recently,  transfusion  by  the  old  method  of  aspiration  and  injection  has  been 



transfusion  was  a  failure  outside  of  increasing  the  volume  of  fluid  in 
the  circulation,  as  the  blood  elements  did  not  retain  their  vitality, 
and  quickly  died  in  the  vessels  of  the  receiver.  Added  to  this,  the 
uncertainty  of  blood-vessel  anastomosis  as  formerly  practised  and 
the  fact  that  transfusion  required  the  use  of  material  and  instruments 
often  difficult  to  procure  in  an  emergency,  materially  limited  the  use- 
fulness of  the  operation,  and  it  became  less  and  less  used.  Finally, 
with  the  introduction  of  infusions  of  normal  salt  solution  as  a  sub- 
stitute, transfusion  practically  became  extinct. 

During  the  past  ten  years,  largely  through  the  work  of  Carrel, 
Crile,  and  others  in  this  country,  transfusion  has  been  revived,  and 
with  the  development  of  improved  methods  of  blood-vessel  anasto- 
mosis it  has  become  a  practical  operation,  the  value  of  which  in  cer- 
tain cases  even  outside  of  hemorrhage  and  shock  seems  to  be  well 
established,  both  experimentally  and  clinically. 

Indications  and  Contraindications. — The  principal  indication  for 
transfusion  is  severe  hemorrhage.  Crile  has  shown  that  if  performed 
early  enough  it  is  a  specific  remedy.  Experimentally  he  has  suc- 
cessfully treated  every  degree  of  hemorrhage;  dogs  were  even  bled  to 
the  last  drop  that  would  flow  and  were  then  successfully  transfused. 
Transfusion  is  also  indicated  in  pathologic  hemorrhage,  where  the 
coagulability  of  the  blood  is  deficient,  as  in  hemophiha,  cholemia, 
hemorrhage  from  the  bowels,  etc.  In  these  cases  the  condition  of  the 
patient  has  been  at  least  improved  by  the  operation  and  in  most 
cases  the  hemorrhage  has  been  controlled.  Some  of  the  reported 
cases  were  transfused  more  than  once  before  permanent  improvement 
was  noted. 

For  shock,  according  to  Crile,  transfusion  is  the  best  form  of 
treatment  we  now  possess.  It  exerts  far  greater  influence  on  blood- 
pressure  than  does  saline  solution.  Both  will  raise  blood-pressure, 
but  the  latter  will  not  maintain  the  rise  in  pressure.  Transfusion, 
on  the  other  hand,  frequently  raises  the  blood-pressure  above  normal 
and  will  sustain  it  at  a  high  level  for  a  number  of  hours. 

For  illuminating-gas  poisoning,  where  chemical  changes  occur 
which  prevent  the  blood  cells  from  giving  up  carbon  dioxid  and  com- 
bining with  oxygen,  venesection  followed  by  transfusion  is  the  best 

In  pellagra  marked  improvement  and  some  cures  have  followed 
the  transfusion  of  blood  from  healthy  donors  or  healed  pellagrins, 
but  it  has  not  proved  as  valuable  a  remedy  in  this  disease  as  was  first 
thought.     The  beneficial  results  are  probably  due  to  an  increased 


resistance  on  the  part  of  the  patient,  due  to  the  restoration  of  the 
blood  to  a  more  normal  condition. 

At  present  the  value  of  transfusion  in  many  other  conditions,  such 
as  tuberculosis,  chronic  suppuration,  acute  infectious  diseases,  etc., 
is  still  undetermined,  and  we  are  not  as  yet  fully  informed  as  to  what 
diseases  contraindicate  its  use.  There  have  been  cases  reported  of 
fatal  hemolysis  after  transfusion  in  pernicious  anemia  and  in  obscure 
blood  diseases,  which  indicate  that  in  some  diseases,  at  least,  trans- 
fusion of  the  blood  of  similar  species  even  is  accompanied  by  danger. 
Until  we  possess  greater  knowledge  of  the  subject,  caution  should  be 
observed  against  the  indiscriminate  employment  of  transfusion. 

Tests  for  hemolysis  should  be  made  upon  the  donor  and  the  recip- 
ient whenever  possible.  Hemolysis  between  the  donor's  corpuscles 
and  the  patient's  serum  is  not  necessarily  harmful,  but  if  it  is  found 
that  there  is  reversed  hemolysis,  that  is,  if  the  donor's  serum  hemol- 
yses the  patient's  corpuscles,  another  donor  should  be  chosen.  Theo- 
retically, agglutination  of  the  red  corpuscles  and  precipitation  may 
also  occur;  though,  according  to  Crile,  in  practice  these  changes  may 
be  disregarded. 

Selection  of  the  Donor. — If  possible,  a  young  vigorous  adult 
should  be  selected  to  supply  the  blood.  The  subject  should  prefer- 
ably be  from  among  the  relatives  of  the  patient — a  close  blood  rela- 
tion, as  a  brother  or  sister,  if  possible.  It  is  essential  that  the  donor 
chosen  be  free  from  arterio-sclerosis,  organic  heart  disease,  malaria, 
syphilis,  etc.,  and  a  thorough  physical  examination,  including  a 
Wassermann  reaction,  should  be  made  to  determine  his  fitness. 


An  anastomosis  between  the  artery  of  the  donor  and  the  vein  of 
the  recipient  may  be  effected  by  means  of  the  special  tubes  of  Crile, 
or  some  of  the  modifications  of  these  tubes,  or  by  means  of  the  direct 
suture  method  of  Carrel.  Crile's  method  is  without  doubt  the  more 
rapidly  and  easily  performed  of  the  two.  It  consists  essentially  of 
slipping  the  tube  over  the  vein,  turning  the  free  end  of  the  vein  back 
over  the  outer  surface  of  the  tube,  and  then  drawing  the  artery  over 
this  venous  cuff.  By  this  method  the  intimae  of  the  vessels  are 
brought  into  apposition  and  there  is  no  foreign  substance  in  contact 
with  the  stream  of  blood,  thus  lessening  the  chance  of  thrombosis. 
Anastomosis  by  direct  suture,  while  it  brings  about  the  same  result, 
is  difficult  to  perform  except  by  one  accustomed  to  blood-vessel  su- 


ture.  In  addition,  there  is  frequently  a  contraction  of  the  vessels 
at  the  point  of  suture,  and  thrombosis  is  more  Hkely  to  occur.  The 
operator  intending  to  perform  transfusion  should,  however,  be  famil- 
iar with  both  methods. 

Instruments. — There  will  be  required  a  scalpel,  an  ordinary  pair 
of  blunt-pointed  scissors,  a  small  pair  of  curved  scissors,  thumb  for- 
ceps, very  fine  tissue  forceps,  two  small  Crile  clamps,  mosquito  hemo- 
stats,  and  transfusion  cannulae.  If  direct  suture  is  employed,  instead 
of  the  Crile  tubes,  there  will  be  needed  several  No.  i6  cambric  needles 
and  fine  strands  of  silk  (Fig.  92).  The  silk  should  be  thoroughly 
impregnated  with  vaselin  and  should  be  threaded  into  the  needles 
before  the  operation  is  begun. 

Fig.  92. — Instruments  for  transfusion,  i,  Scalpel;  2,  thumb  forceps;  3, 
blunt-pointed  scissors;  4,  mosquito  hemostats;  5,  fine  tissue  forceps;  6,  Crile 
clamps;  7,  small  pair  of  curved  scissors;  8,  Crile  cannulas;  9,  needles  threaded  with 
fine  strands  of  silk. 

The  tube  devised  by  Crile  is  of  German  silver  and  is  provided  with 
a  small  handle  and  with  two  grooves  upon  the  outer  surface  of  the 
cannula  portion  into  which  fit  the  ligatures  holding  the  vein  and 
artery  in  place  (Fig.  94).  At  least  four  sizes  of  these  tubes  should  be 
at  hand,  and  the  largest  size  that  can  be  used  without  injury  to  the 
arterial  coats  by  undue  stretching  should  be  employed. 

To  avoid  the  necessity  of  having  several  sizes  of  cannulae  and  to 
furnish  an  instrument  that  can  be  more  easily  manipulated,  Buerger 
has  devised  a  cannula  which  is  supplied  with  a  long  handle  and  is 
made  with  a  slit  in  the  circumference  of  the  tube  so  that  it  is  possible 
to  alter  the  diameter  of  the  cannula  to  fit  the  individual  vessels  (Fig. 



Position  of  the  Donor  and  Recipient. — The  donor  should  lie  upon 
an  operating-table  of  such  make  that  will  permit  his  head  to  be 
quickly  lowered  if  he  becomes  faint  while  the  operation  is  in  progress. 
The  recipient  is  placed  upon  a  second  table,  with  the  head  turned  in 
the  opposite  direction.  Both  tables  should  be  provided  with  cush- 
ions or  a  layer  of  pillows,  so  that  the  patients  will  be  comfortable 
during  the  operation.     Between  the  two  operating- tables  is  placed  a 

Fig.  93. — Enlarged  view  of  Crile's  clamps.     (After  Fowler.)      I,  Clamp  without 
rubbers;  2,  rubber  tubes  to  fit  on  jaws  of  clamps;  3,  clamp  applied  to  artery. 

small  square  table  upon  which  the  arms  of  the  donor  and  recipient 
rest  during  the  operation.  The  operator  is  seated  upon  a  stool  in 
front  of  this  table,  and  his  assistant  opposite  (Fig.  96). 

Asepsis. — The  strictest  asepsis  must  be  observed  during  the 
entire  operation.  The  instruments  are  boiled,  and  the  hands  of  the 
operator  are  prepared  in  the  usual  way.     The  forearms  of  the  donor 

Fig.  94. — Enlarged  view  of  Crile's  cannula. 
Fig.  95. — Buerger's  cannula. 

and  the  recipient  should  be  sterilized  by  painting  with  tincture  of 

Anesthesia. — The  operation  is  performed  under  local  anesthesia, 
employing  a  0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  solution 
of  novocain  for  the  skin  and  a  o.i  per  cent,  cocain  solution  or  a 
0.5  per  cent,  solution  of  novocain  for  deeper  infiltration. 

Quantity  Transfused. — It  is  impossible  to  estimate  the  exact 
amount  of  blood  transfused  and  the  guides  should  be  the  condition  of 


the  donor  and  the  recipient;  the  amount  should  also  vary  according 
to  the  condition  for  which  the  transfusion  is  performed.  Twenty 
to  forty-live  minutes'  flow  in  a  good  anastomosis  is  usually  sufficient. 
As  soon  as  the  donor  shows  signs  of  loss  of  blood — indicated  b}-  a 
gradual  pallor  about  the  nose  and  ears,  deepening  of  the  lines  of 
expression,  sighing  or  irregular  respiration,  etc. — the  transfusion 
must  be  immediately  stopped.  If  it  is  carried  too  far,  the  donor 
goes  into  a  state  of  collapse,  and  a  condition  is  produced  in  him  similar 
to  that  for  the  relief  of  which  the  operation  was  performed.  Fur- 
thermore, transfusion  of  excessive  am.ounts  of  blood  may  cause  ser- 

Upe  rating   7a hie 
J  /Lecipient~ 

0.     0 

Operating  /ahle. 
Z  jDonor 

Fig.  96. — Arrangement  of  the  operating-tables  for  a  transfusion.  (After 
Crile.)  I,  Table  for  recipient;  2,  table  for  donor;  3,  table  for  arms  of  recipient 
and  donor;  4  and  5,  stools  for  operator  and  assistant;  6,  instrument  table;  7, 
table  for  dressings,  etc. 

ious  damage  to  the  viscera  of  the  recipient,  and  even  death.  Acute 
dilatation  of  the  heart,  manifested  by  dyspnea,  cyanosis,  cough, 
pain  over  the  precordium,  and  falling  blood-pressure,  is  the  most 
frequent  sequel  to  overtransfusion.  Should  such  a  complication 
ensue,  the  transfusion  must  be  immediately  stopped,  the  patient 
should  be  placed  in  a  reverse  Trendelenburg  position  with  the  feet 
lowered,  and  external  massage  of  the  heart  (page  54)  performed  to 
assist  in  emptying  it. 

Rapidity  of  Flow. — The  rate  with  which  the  blood  flows  from  the 
donor  to  the  recipient  should  be  carefully  gauged,  for  fear  of  over- 
charging the  heart  and  producing  an  acute  cardiac  dilatation.  This 
may  be  determined  by  noting  the  strength  of  the  pulsation  in  the 
veins.  If  too  strong,  the  flow  may  be  regulated  by  partially  com- 
pressing the  lumen  of  the  artery  by  means  of  the  fingers. 



Teclinic  by  Crile's  Method. — The  radial  artery  of  the  donor  and 
any  of  the  superficial  A-eins  in  front  of  the  elbow  of  the  recipient  are 
chosen  for  making  the  anastomosis — in  a  child  the  pophteai  vein 
may  be  utilized.  Both  the  donor  and  the  recipient  are  given  1/4 
gr.  (0.0162  gm.)  of  morphin  hA-podermically  half  an  hour  before  the 
operation  unless  it  is  contraindicated. 

The  area  of  incision  is  infiltrated  T^dth  cocain,  and  about  i  1/2 
inches  (4  cm.)  of  the  radial  artery  is  exposed  and  dissected  free. 
Any  branches  are  avoided  if  possible;  if  they  cannot  be  avoided,  they 
may  be  tied  off  with  fine  silk  and  cut  close  to  the  trunk.  A  Crile 
clamp  is  gently  applied  as  high  as  possible  to  the  proximal  end  of 

Fig.  97. — Transfusion  bj'  Crile's  method.     First  step,  exposure  of  the  vein  and 
artery  with  Crile's  clamps  applied. 

the  artery,  or,  in  the  absence  of  a  special  clamp,  a  piece  of  tape 
may  be  placed  around  the  artery  and  clamped  sufficiently  tight  to 
compress  the  vessel  and  shut  ofi'  the  circulation.  The  distal  end  of 
the  artery  is  then  ligated  and  the  vessel  is  cut.  The  adventitia  is 
pulled  over  the  end  of  the  vessel  and  is  snipped  ofi'  as  clean  as  possible. 
The  field  of  operation  is  now  covered  vnth  a  compress  well  soaked 
with  hot  saline  solution.  The  vein  of  the  recipient  is  then  exposed 
in  the  same  manner,  and  about  i  i/'2  inches  (4  cm.)  of  it  is  freed  from 
the  surrounding  tissues.  The  distal  end  of  the  vein  is  ligated,  and 
to  the  proximal  end  is  applied  a  Crile  clamp  CFig.  97),  or  a  narrow 
piece  of  tape  fastened  as  described  above.  The  vessel  is  divided  and 
the  adventitia  is  snipped  off  after  pulling  it  out  over  the  end  of  the 
vessel.  A  Crile  cannula  of  appropriate  size,  held  in  an  artery  clamp, 
is  pushed  over  the  vein.  A  suture  inserted  in  the  edge  of  the  vein, 
as  shown  in  Fig.  98,  aids  in  drawing  the  latter  through  the  cannula. 
The  projecting  portion  of  the  vein  is  seized  by  three  mosquito  clamps 
and  is   turned  back   as  a  cuff  (Fig.  99),  and  is  tied  in  the  second 


groove  of  the  cannula.  The  forearms  of  the  donor  and  the  recipient 
are  then  placed  so  that  the  hand  of  the  donor  is  directed  toward  the 
elbow  of  the  recipient.     The  cuffed  portion  of  the  vein  is  lubricated 

Fig.  98.  Fig.  99.  Fig.  100. 

Fig.  98. — Transfusion  by  Crile's  method.  (After  Crilc.)  Second  step,  draw- 
ing the  vein  through  the  cannula. 

Fig.  99. — Transfusion  by  Crile's  method.  (After  Crile.)  Third  step, 
method  of  cuffing  back  the  vein. 

Fig.  100. — Transfusion  by  Crile's  method.  (After  Crile.)  Fourth  step, 
showing  the  vein  cuffed  back  over  the  cannula  and  the  method  of  drawing  the  artery 
over  the  vein. 

with  sterile  vaselin,  three  mosquito  forceps  are  applied  to  the  edges 
of  the  artery,  and  it  is  gradually  drawn  down  over  the  cuffed  vein 
(Fig.  100)  and  is  tied  in  place  by  a  silk  ligature  which  fits  into  the 
first  groove  on  the  cannula.     The  clamp  is  removed  from  the  vein 

Figs.   101   and    102. — Transfusion   by   Crile's  method. 

anastomosis  completed. 

Fifth  step,  showing  the 

first.  The  clamp  upon  the  artery  is  then  very  gradually  opened, 
allowing  the  blood  to  flow  into  the  vein  of  the  recipient  (Figs.  loi 
and  102).     At  the  completion  of  the  operation  the  vessels  are  ligated, 


the  tube  is  excised,  and  the  skin  incision  is  sutured  and  dressed 
with  sterile  gauze. 

In  performing  the  operation  there  are  several  precautions  to  be 
observed.  The  vessels  to  be  anastomosed  must  be  handled  with  the 
greatest  care.  They  should  never  be  bruised  with  artery  clamps  or 
picked  up  with  toothed  forceps.  Some  difficulty  may  be  experienced 
from  retraction  of  the  vessels  when  they  are  cut.  This  may  be  over- 
come to  a  great  extent  by  keeping  them  constantly  moistened  with 
hot  saline  solution.  In  the  case  of  a  contracted  artery,  Crile  advises 
that  it  be  dilated  by  gently  inserting  a  fine  pair  of  closed  artery  clamps 
covered  with  vaselin  and  using  it  as  one  would  a  glove  stretcher. 
Care  should  be  taken  that  the  anastomosis  be  made  without  undue 
tension,  and  that  the  cannula  be  placed  accurately  in  the  long  axis 
of  the  vein  and  artery,  otherwise  the  flow  will  be  more  or  less  impeded. 

Fig.   103. — Brewer's  glass  tubes  lined  with  paraffin  for  transfusion. 

Variations  in  Technic. — Brewer  has  simplified  Crile's  method 
of  making  an  anastomosis  by  employing  long  glass  tubes  lined  with 
paraffin  (Fig.  103).  These  tubes  are  about  2  1/2  inches  (6  cm.)  long, 
and  are  made  small  at  the  end  to  be  inserted  into  the  artery  and  large 
at  the  end  over  which  the  vein  is  drawn.  Each  end  is  slightly  bul- 
bous, and  is  provided  with  a  sulcus  into  which  the  ligature  holding 
the  vessel  in  place  falls. 

The  tubes  are  thoroughly  sterilized  and  are  then  dipped  in 
melted  paraffin,  shaken  out,  and  allowed  to  cool.  The  vein  and 
artery  are  exposed  and  isolated  in  the  usual  way  and  two  Crile  clamps 
are  applied  as  shown  in  Fig.  97.  The  artery  is  drawn  over  one  end  of 
the  tube  and  is  secured  by  a  ligature.  A  longitudinal  or  a  transverse 
cut  is  made  in  the  wall  of  the  vein  (see  Fig.  118),  and,  after  loosening 
the  arterial  clamp  sufficiently  to  permit  the  tube  to  fill  with  blood, 
the  distal  end  of  the  tube  is  quickly  inserted  into  the  vein  in  the 
manner  shown  in  Fig.  119,  and  is  secured  in  place  by  a  ligature.  The 
clamps  are  then  removed  and  the  blood  is  allowed  to  flow. 


It  is  claimed  that  the  length  of  these  tubes  and  the  ease  with 
which  they  are  inserted  into  the  vessels  render  the  operation  consider- 
ably less  difficult. 

Hartwell  {Journal  of  the  American  Medical  Association,  Jan.  23, 
1909)  has  devised  a  method  of  tranfusion  without  the  use  of  a  cannula 
by  simply  inserting  the  artery  into  the  vein.  He  describes  the 
method  as  follows:  "The  artery  and  vein  are  dissected  out,  tempo- 
rarily clamped  and  divided  in  the  usual  manner,  with  the  usual  care 
in  securing  the  small  branches.  The  adventitia  is  removed  from  each, 
but  a  small  coil  of  it  is  left  curled  up  on  the  outside  of  the  artery  about 
I  1/2  inches  (4  cm.)  from  the  cut  proximal  end.  Three  guiding 
sutures  of  fine  silk  are  then  passed  by  means  of  a  fine  needle — an 
ordinary  intestinal  needle  and  zero  silk  are  sufficiently  fine — at 
intervals  of  120  degrees  in  the  circumference  of  the  cut  end  of  the 
vein.  The  end  of  the  artery  is  greased  with  melted  sterilized  petro- 
latum.    The  mouth  of  the  vein  is  drawn  open  with  the  sutures,  and 

Fig.    104. — Levin's  transfusion  clamp. 

the  artery  is  passed  directly  into  it  for  a  distance  of  an  inch  (2.5  cm.). 
One  of  the  guiding  sutures  is  then  passed  through  the  rolled  up 
adventitia  on  the  artery,  to  hold  the  two  vessels  in  contact,  and  the 
greater  or  less  amount  of  superfluous  circumference  of  the  vein  is 
clamped  or  sutured  so  as  simply  to  approximate  the  artery  but  not 
to  constrict  it.  The  obstructing  clamps  are  removed,  and  the  blood 
current  is  allowed  to  flow." 

Levin  {Annals  of  Surgery,  ]March,  1909)  describes  a  clamp  form 
of  transfusion  cannula.  This  instrument  (Fig.  104)  is  made  in  the 
form  of  an  artery  clamp  with  a  small  cannula  attached  to  the  tip 
of  each  blade.  Upon  the  free  edge  of  each  cannula  are  placed  four 
small  pin  points,  and  upon  the  outer  surface  are  four  grooves  into 
which  the  pins  fit  when  the  two  cannulas  are  in  contact. 

To  perform  an  anastomosis  with  this  instrument  the  two  halves 
of  the  instrument  are  separated.  The  cut  vein  is  passed  through  one 
cannula  and  its  wall  is  hooked  on  the  pins.  The  artery  is  treated  in 
a  similar  manner,  and  then  both  halves  of  the  instrument  are  united 
and  clamped. 


Elsberg  {Journal  of  the  American  Medical  Association,  March 
13,  1909)  describes  a  very  practical  cannula  that  does  away  with  the 
necessity  for  the  Crile  clamps.  His  method  of  performing  the  anasto- 
mosis differs  from  the  Crile  method  in  several  points.  "The  cannula 
(Fig.  105)  is  built  on  the  principle  of  a  monkey  wrench,  and  can  be 
enlarged  or  narrowed  to  any  size  desired  by  means  of  a  screw  at  its 
end.  The  smallest  lumen  obtainable  is  about  equal  to  that  of  the 
smallest  Crile  cannula,  and  the  largest  greater  than  the  lumen  of  any 
radial  artery.  The  instrument  is  cone-shaped  at  its  tip,  a  short  dis- 
tance from  which  is  a  ridge  with  four  small  pin  points  which  are 
directed  backward.  The  lumen  of  the  cannula  at  its  base  is  larger 
than  at  its  tip." 

In  using  this  instrument,  after  first  exposing  and  separating  the 
artery  from  the  surrounding  tissues  in  the  usual  manner,  the  cannula 

Fig.   105. — Elsberg's  transfusion  cannula. 

is  widely  opened  and  is  placed  around  the  artery  before  the  latter  is 
cut.  The  cannula  is  then  screwed  together,  thereby  shutting  off  the 
arterial  flow.  The  distal  end  of  the  artery  is  next  ligated  at  about 
1/2  inch  (i  cm.)  from  the  end  of  the  cannula,  and  three  fine  silk  trac- 
tion sutures  or  small  tenacula  are  passed  through  the  artery  at  equi- 
distant points  on  its  circumference  a  short  distance  from  the  ligature. 
The  artery  is  then  cut  close  to  the  ligature,  and  the  end  is  cuffed  back 
by  drawing  upon  the  traction  stitches  or  tenacula  and  is  caught  in  the 
teeth  upon  the  clamp.  The  vein  of  the  recipient  is  then  exposed  and 
two  ligatures  are  applied,  the  distal  one  being  tied  (see  Fig.  117). 
The  vein  is  opened  by  means  of  a  small  transverse  slit  in  the  same 
manner  as  for  an  intravenous  infusion  (see  Fig.  118),  and  the  cannula 
with  the  cuffed  artery  is  inserted  into  the  vein  and  tied  securely  in 
place  by  means  of  the  loose  ligature.  The  cannula  is  then  screwed 
open  and  the  blood  is  allowed  to  flow,  the  rapidity  of  flow  being  con- 
trolled by  the  extent  to  which  the  cannula  is  opened. 

Technic  by  Carrel's  Suture.— Under  local  anesthesia  the  radial 
artery  of  the  donor  and  the  median  basilic  vein  of  the  recipient  are 
dissected  free  for  a  distance  of  i  1/2  inches  (4  cm.),  and  any  small 
branches  are  tied  off  with  fine  silk  close  to  the  main  trunk.  A  small 
Crile  clamp  is  applied  to  the  proximal  portion  of  the  artery  as  near  as 


possible  to  the  upper  limit  of  the  incision,  and  the  distal  end  of  the 
vessel  is  tied  off.  The  artery  is  then  cut  close  to  the  distal  ligature 
and  the  adventitia  is  drawn  down  over  the  end  of  the  vessel  and 
trimmed  off.  The  field  of  operation  is  then  covered  by  a  pad  mois- 
tened in  saline  solution,  while  the  attention  of  the  operator  is  directed 

Fig.   106.  Fig.  107. 

Fig.  106. — Transfusion  by  Carrel's  suture.  (After  Carrel.)  First  step,  show- 
ing the  method  of  inserting  the  three  traction  sutures. 

Fig.  107. — Transfusion  by  Carrel's  suture.  (After  Carrel.)  Second  step,  the 
three  traction  sutures  in  place. 

to  preparing  the  vein.  The  extreme  distal  end  of  the  vein  is  tied  off 
with  a  ligature,  a  Crile  clamp  is  applied  to  the  proximal  portion,  and 
the  vessel  is  severed  close  to  the  distal  ligature  (see  Fig.  97).  The 
end  of  the  vein  is  then  trimmed  of  its  adventitia,  as  was  the  artery. 
The  arms  of  the  donor  and  the  recipient  are  placed  near  together  upon 

Fig.   108.  Fig.  109. 

Fig.  108. — Transfusion  by  Carrel's  suture.  (After  Carrel.)  Third  step, 
showing  the  method  of  suturing  the  artery  and  vein. 

Fig.  109.— Transfusion  by  Carrel's  suture..  (After  Carrel.)  Fourth  step, 
the  anastomosis  completed. 

a  small  table,  so  that  the  vessels  may  be  brought  together  without 
tension,  the  hand  of  the  donor  pointing  toward  the  elbow  of  the 
recipient.  The  ends  of  the  two  vessels  are  then  sutured  together  as 


The  needle,  threaded  with  a  fine  strand  of  silk  impregnated  with 
vaselin,  is  passed  through  the  wall  of  the  artery  from  without  in  and 
through  the  wall  of  the  vein  (Fig.  io6),  and  the  two  ends  of  the  suture 
are  tied  and  left  long,  to  serve  as  a  traction  stitch.  Two  other  sutures 
are  similarly  placed  at  such  points  that  the  circumference  of  the 
vessels  is  divided  into  three  equal  parts  (Fig.  107).  Two  of  these 
traction  sutures  are  made  taut,  and  the  walls  of  the  vessels  between 
them  are  readily  sutured.  A  continuous  stitch  is  employed  for  this, 
the  stitches  being  placed  near  the  edges  of  the  vessels  and  close  to- 
gether to  prevent  leakage  (Fig.  108).  Before  performing  this  sutur- 
ing a  clamp  should  be  attached  to  the  third  traction  stitch  and  should 
be  allowed  to  hang  from  below  so  as  to  open  the  lumen  of  the  vessel 
and  thus  avoid  including  other  portions  of  the  intima  in  the  suture. 
As  soon  as  one-third  of  the  vessels  is  united,  the  next  two  traction 
stitches  are  made  taut  and  another  third  is  sutured,  the  clamp  being 
again  shifted  to  the  under  stay.  The  remaining  third  is  united  in 
precisely  the  same  manner,  thus  completing  the  suturing  around  the 
entire  circumference  of  the  two  vessels  (Fig.  109).  The  clamp  upon 
the  vein  is  removed  first,  and  then  the  arterial  clamp  is  slowly  un- 
screwed, allowing  the  blood  to  gradually  flow  from  one  vessel  into 
the  other.  If  the  sutures  are  properly  applied,  there  should  be  but 
little,  if  any,  leakage  at  the  line  of  union. 


In  place  of  the  artery  to  vein  method,  vein  to  vein  transfusion 
has  been  advocated  by  Dorrance  and  Ginsburg  as  being  simpler  and 
easier  to  perform  than  artery  to  vein  anastomosis  on  account  of  the 
superficial  location  of  the  vessels.  Another  advantage  claimed  for 
this  method  is  that  the  flow  of  blood  being  slower,  the  danger  of  pro- 
ducing acute  dilatation  of  the  heart  is  avoided.  Vein  to  vein 
anastomosis  may  be  performed  by  the  direct  suture  method  of  Carrel 
or  by  means  of  any  of  the  mechanical  devices  already  described  under 
artery  to  vein  transfusion.  Fauntleroy  has  devised  paraffin-coated 
curved  glass  tubes,  somewhat  similar  to  those  of  Brewer,  by  the  use 
of  which  vein  to  vein  transfusion  is  very  much  simplified. 

Technic. — The  arm  of  the  donor  is  constricted  immediately  below 
the  axilla  with  a  tourniquet  applied  with  just  sufiicient  tension  to 
distend  the  superficial  veins  but  not  tight  enough  to  obstruct  the 
arterial  flow.  This  causes  the  superficial  veins  to  dilate  and  stand 
out  prominently.     The  veins  of  the  recipient  are  similarly  treated. 


Under  infiltration  anesthesia  the  median  cephalic  or  the  median 
basilic  veins  of  both  the  donor  and  the  recipient  are  exposed  through 
a  3-inch  (7.5  cm.)  incision  and  an  anastomosis  between  the  distal  end 
of  the  donor's  vein  and  the  proximal  end  of  the  recipient's  vein  is 
made  by  some  of  the  methods  previously  described  under  artery  to 
vein  anastomosis.  As  soon  as  the  anastomosis  is  completed  the 
tourniquet  is  removed  from  the  recipient's  arm  while  that  upon  the 
donor's  arm  is  simply  loosened,  being  left  with  sufficient  tension  to  pro- 
duce a  well-marked  hyperemia  and  an  increase  in  the  venous  pres- 
sure. In  this  way  there  is  enough  pressure  created  in  the  vein  of  the 
donor  to  cause  the  blood  to  flow  freely  into  the  vein  of  the  recipient. 
By  this  method  the  flow  of  blood  will  be  less  rapid  than  in  an  artery 
to  vein  anastomosis  and  the  transfusion  will  need  to  be  continued 
over  a  longer  period  of  time. 


For  manv  vears  it  has  been  known  that  blood  serum  contained 
some  agent  that  hastened  the  coagulation  of  blood.  In  1882  Hayem 
estabhshed  this  fact  while  performing  experiments  with  different 
sera  to  determine  their  effect  on  coagulation.  It  is  only,  however, 
since  Weil  in  1905  published  the  results  of  his  work  along  this  line 
that  the  injection  of  fresh  animal  and  human  serum  has  become  gen- 
erally recognized  as  a  method  of  value  for  the  prevention  and  control 
of  certain  forms  of  hemorrhage,  such  as  is  seen  in  hemophilia,  chole- 
mia,  and  purpuric  conditions  supposed  to  be  dependent  upon  defi- 
cient coagulability  of  the  blood.  ]More  recently  Welch  of  New  York 
has  shown  that  the  subcutaneous  injection  of  human  blood  serum 
is  almost  a  specific  remedy  for  the  treatment  of  hemophilia  neona- 
torum; from  the  rapid  gain  in  weight  after  its  use  he  also  considers 
it  a  most  efficient  food  for  premature  and  malnourished  infants. 
Blood  serum  is,  likewise,  claimed  to  be  of  value  in  septic  conditions 
on  account  of  its  bactericidal  action. 

Wbile  horse  serum,  rabbit  serum,  and  human  serum  have  all 
been  employed  in  these  cases  of  pathologic  hemorrhage,  the  latter 
should  always  be  used  in  preference.  With  animal  sera  there  is 
danger  of  producing  serum  sickness  and  anaphylaxis,  especially  where 
repeated  injections  are  made,  but  this  is  apparently  not  the  case 
with  human  serum. 

It  should  be  remembered  that,  while  the  injection  of  human  serum 
is  an  efficient  method  of  controlling  pathologic  hemorrhages,  it  does 



not,  of  course,  replace  the  cellular  elements  lost  through  excessive 
bleeding.  In  such  cases,  where  the  cellular  elements  are  greatly 
diminished,  transfusion  is  indicated. 

Apparatus. — The  apparatus  for  collecting  the  blood,  described  by 
Welch  {American  Journal  of  Medical  Sciences,  June,  19 10),  consists, 
of  an  Erlenmeyer  flask  stoppered  with  a  rubber  cork  through  which 
are  two  perforations.  Through  one  is  fitted  a  U-shaped  tube,  to  the 
outer  end  of  which  is  attached  a  short  aspirating  needle  of  No.  19 
caliber  by  means  of  a  rubber  tubing.  The  needle  is  cotton  plugged 
in  a  small  test-tube  in  which  it  is  sterilized. 
Through  the  other  perforation  is  inserted  a 
fusiform  glass  tube  containing  cotton  to  pre- 
vent contaminating  the  contents  of  the  flask. 
Upon  the  end  of  this  tube  is  placed  a  small 
suction  tube  for  drawing  the  blood  into  the 
flask  (Fig.  no). 

A  30  to  60  c.c.  (i  to  2  ounces)  glass  syringe 
with  a  glass  piston  should  be  provided  for  in- 
jecting the  serum. 

Selection  of  Donor. — Preferably  young 
adults  from  among  the  relatives  of  the  patient 
should  be  selected.  The  donors,  of  course, 
must  be  free  from  any  constitutional  or  other 
disease,  and  a  thorough  physical  examination, 
including  a  Wassermann  test,  should  be  made 
to  determine  their  fitness. 

Dosage. — In  hemophilia  neonatorum  Welch 
advises  that  i  ounce  (30  c.c.)  of  serum  be  given 
twice  a  day  to  moderate  bleeders  and,  if  the  bleeding  is  excessive, 
that  it  be  given  every  four  hours  until  the  bleeding  is  under  control. 

As  a  preventive  of  postoperative  hemorrhage  in  chronic  jaundice, 
Willy  Meyer  advises  that  i  to  2  ounces  (30  to  60  c.c.)  of  serum  be 
administered  three  times  a  da,y  beginning  two  days  before  the  opera- 
tion and  continuing  for  forty-eight  to  seventy- two  hours  afterward. 

Site  of  Injection. — The  serum  is  injected  subcutaneously  in  the 
loose  tissues  of  the  axilla  or  in  the  subcutaneous  tissues  of  the  abdo- 
men on  either  side  of  the  umbilicus.  In  cases  of  great  urgency  it  may 
be  given  intravenously. 

Asepsis. — The  apparatus  for  collecting  the  blood  and  the  syringe 
for  injecting  the  serum  should  be  sterilized,  the  operator's  hands 
should  be  cleansed  as  for  any  operation,  and  the  arm  of  the  donor 

Fig.  1 10. — Welch's 
apparatus  for  collect- 
ing blood  serum. 


and  the  site  of  injection  are  sterilized  by  painting  with  tincture  of 

Technic. — To  collect  the  blood,  a  tourniquet  is  first  placed  about 
the  arm  of  the  donor  with  sufficient  tension  to  make  the  veins  stand 
out  prominently.  One  of  the  veins  at  the  bend  of  the  elbow — prefer- 
ably the  median  basilic — is  then  identified  and  the  needle  of  the 
collecting  apparatus  is  thrust  into  it,  holding  the  needle  almost  paral- 
lel with  the  skin  surface.  About  lo  ounces  (300  c.c.)  of  blood  is  then 
drawn  into  the  flask,  which  is  promptly  stoppered  with  a  sterile  plug 
of  cotton.  The  flask  is  then  placed  in  a  slanting  position  until  the 
serum  has  formed.  It  usually  takes  four  to  six  hours  for  all  the  serum 
to  separate.  When  this  has  taken  place,  the  serum  is  transferred 
to  a  sterile  flask  and  is  placed  on  ice  until  used. 

The  technic  of  injecting  the  serum  is  as  follows:  The  neck  of  the 
flask  is  sterilized,  and  the  desired  quantity  of  serum  is  drawn  into 
the  syringe.  Care  should  be  taken  to  see  that  all  the  air  is  ex- 
pelled from  the  syringe.  A  fold  of  skin  in  the  region  decided  upon 
for  making  the  injection  is  then  raised  up  between  the  thumb  and 
forefinger  of  the  left  hand,  and,  with  the  right  hand  the  needle  is 
quickly  thrust  into  the  subcutaneous  tissues  at  the  base  of  this  fold 
of  skin.  The  serum  is  injected  slowly,  and  the  resulting  swelling 
is  very  gently  massaged  until  the  serum  is  all  absorbed.  After 
withdrawal  of  the  needle,  the  point  of  puncture  is  sealed  with 
collodion  and  cotton.  Usually  within  twenty-four  of  forty-eight 
hours  after  beginning  the  injections  the  bleeding  will  be  controlled. 


The  administration  of  physiological  salt  solution  was  originally 
introduced  as  a  substitute  for  transfusion  of  blood  in  the  treatment 
of  hemorrhage  on  account  of  the  numerous  risks  that  attended  the 
latter  operation  as  formerly  performed,  and  the  difficulty  of  obtain- 
ing a  suitable  donor  when  most  needed.  The  technic  of  direct  blood 
transfusion  has,  however,  been  wonderfully  perfected,  and  it  can 
now  be  said  to  be  an  operation  without  danger  if  employed  with 
proper  precautions;  but,  notwithstanding  this  and  the  fact  that  no 
media  has  been  found  as  efficient  as  blood  in  making  up  the  loss 
from  a  severe  hemorrhage,  the  infusion  of  salt  solution  is  employed 
in  preference  to  transfusion  in  the  great  majority  of  cases.  This 
may  be  readily  understood  when  we  consider  that  the  methods  of 
administering  salt  solution  can  be  carried  out  on  short  notice,  that 
they  require  but  little  preparation,  that  they  are  marked  by  sim- 
plicity in  technic,  and  that  they  are  within  the  reach  of  all;  on 
the  other  hand,  transfusion  becomes  a  formidable  operation  in 
comp  arison. 

Salt  solution  may  be  introduced  into  the  circulation  through  a 
vein  (intravenous  infusion),  through  an  artery  (intraarterial  infu- 
sion), through  the  subcutaneous  tissues  (hypodermoclysis),  and  by 
way  of  the  bowel  (rectal  infusion). 

Indications. — The  use  of  physiological  salt  solution  is  indicated 
in  the  following  conditions: 

(i)  In  collapse  following  severe  hemorrhage  to  replace  the  cir- 
culating fluid,  thus  giving  the  heart  a  volume  of  fluid  to  contract 
upon  and  raising  blood-pressure.  Salt  solution,  however,  cannot 
replace  the  cellular  constituents  of  the  blood,  and  in  the  severest 
grades  of  hemorrhage,  when  the  number  of  oxygen-carrying  red  cells 
falls  below  a  certain  point,  the  injection  of  fluids  into  the  circulation 
will  not  avail — only  the  transfusion  of  blood  can  avert  a  fatal  issue 
in  such  cases. 

(2)  In  the  prophylaxis  and  treatment  of  mild  surgical  shock,  for 
the  purpose  of  restoring  heat  to  the  body  and  raising  arterial  tension. 
As  shown  by  Crile,  however,  in  severe  shock,  unless  due  to  hemor- 



rhagc,  the  rise  of  blood-pressure  is  so  temporary  that  the  first  benefits 
derived  from  the  infusion  are  not  maintained.  In  such  cases,  the 
combination  with  the  salt  solution  of  drugs  which  raise  blood-pressure, 
such  as  adrenalin  chlorid,  is  followed  by  more  marked  and  beneficial 
results.  For  a  single  infusion,  10  to  30  Tn,(o.6  to  2  c.c.)  of  the  i  to 
1000  solution  of  adrenalin  chlorid  may  be  added  to  a  pint  (500  c.c.) 
of  salt  solution,  or  the  adrenalin  may  be  administered  by  thrusting 
a  hypodermic  needle  into  the  rubber  tubing  near  the  cannula  and 
injecting  the  drug  as  the  solution  flows  into  the  vein. 

(3)  To  increase  the  fluids  in  the  tissues  where  there  is  deficient 
absorption  of  food,  as  in  excessive  vomiting,  peritonitis,  etc.,  or  to 
replace  the  fluids  lost  through  purging,  as  in  dysentery  and  cholera. 
The  administration  of  salt  solution  may  also  be  used  to  advantage 
before  undertaking  operations  upon  poorly  nourished  individuals. 

(4)  For  its  stimulating  effects  and  the  production  of  a  rapid 
elimination  of  impurities  from  the  body  by  causing  diuresis,  saline 
infusion  is  indicated  in  suppression  of  urine,  uremia,  diabetic  coma, 
eclampsia,  septicemia,  various  forms  of  toxemia,  and  in  poisoning 
from  carbonic  acid  gas,  illuminating  gas,  etc. 

(5)  For  the  purpose  of  relieving  postoperative  thirst. 

The  administration  of  saline  solution  is  contraindicated  in  ad- 
vanced dropsy,  pulmonary  edema,  or  marked  cardiac  insufficiency. 

Preparation  of  the  Solution. — To  be  exact,  normal  physiological 
salt  solution  that  is  isotonic  with  the  blood,  consists  of  nine  parts 
sodium  chlorid  to  one-thousand  parts  of  water.  A  variation  in  the 
strength  of  the  solution  between  0.6  per  cent,  and  0.9  per  cent,  is 
permissible,  however,  and  in  practice  the  solution  is  generally  made 
up  in  the  strength  of  0.7  per  cent. — roughly,  i  dram  (4  gm.)  of  chem- 
ically pure  sodium  chlorid  to  a  pint  (500  c.c.)  of  distilled  water.  It 
is  of  the  utmost  importance  that  the  solution  be  accurately  made, 
and  it  should  not  vary  much  from  this  strength  of  seven  parts  per 
thousand,  as  solutions  not  isotonic  with  the  blood  produce  certain 
untoward  changes  in  the  corpuscles.  It  is  the  opinion  of  Mummery 
that  symptoms,  such  as  chills  and  sweating,  which  are  sometimes 
seen  after  intravenous  infusions,  are  due  to  the  incorrect  chemical 
composition  of  the  fluid  employed.  Carelessness  in  this  respect, 
as  well  as  disregard  of  the  proper  temperature  of  the  solution,  are 
without  doubt  also  responsible  for  many  of  the  cases  of  reported 
sloughing  of  the  tissues  after  subcutaneous  infusion. 

A  convenient  method  of  keeping  the  salt  solution  ready  for  use 
is  to  have  a  sterilized  and  very  concentrated  solution  put  up  in 


hermetically  sealed  tubes,  in  such  a  strength  that  the  contents  of 
one  tube  emptied  into  a  quart  <  looo  c.c.j  of  sterile  water  gives  a 
normal  salt  solution  (Fig.  in).  In  hospital  practice  it  is  customary 
to  keep  the  solution  in  stock  bottles  ready  for  use.  The  solution  is 
made  up  in  the  proper  strength  from  sterile  salt  dissolved  in  sterile 
water,  and  is  then  prepared  as  follows.^  "■  Filter  into  flasks  (sterilized 
by  washing  with  bichlorid  solution,  then  rinsing  with  sterile  water) 
stoppered  with  nonabsorbent  cotton,  sterilize  for  one  hour  for  three 
successive  days  at  a  temperature  of  220°  F.,  and  cover  the  cotton 
stoppers  wdth  a  small  square  of  rubber  tissue  held  in  place  by  a 
rubber  band.  Wlien  needed,  place  the  flask  in  a  deep  basin  filled 
with  hot  water  until  raised  to  the  proper  temperature."'     A  more 

Fig.    III. — A  tube  of  concentrated  sterile  salt  solution. 

convenient  method  of  bringing  the  solution  to  the  required  tempera- 
ture W'hen  needed  for  use  is  to  have  at  hand  very  hot  and  cold  salt 
solutions  in  separate  flasks.  The  solution  may  be  quickly  heated 
by  placing  the  flasks,  surrounded  by  water  to  their  necks,  in  a  steril- 
izer or  a  deep  basin,  and  bringing  the  water  to  the  boiling-point. 
Some  of  the  cold  solution  is  poured  into  the  reservoir  first,  and  suffi- 
cient of  the  hot  solution  is  then  added  to  bring  the  contents  of  the 
reservoir  to  the  proper  temperature. 

Other  Solutions  Employed. — Some  operators  prefer  to  employ 
artificial  sera  prepared  according  to  certain  fromul^,  the  object  being 
to  obtain  a  solution  as  nearly  identical  to  the  blood  serum  as  possible. 
Some  of  those  most  frequently  used  are  as  follows: 

Hare's  formula:  (Approximately.) 

Calcium  chlorid, 

0.25  gm. 

gr.  iv. 

Potassium  chlorid, 

0. 10  gm. 

gr.  I  12 

Sodium  chlorid, 

9        gm. 

dr.  2  1,4 

Distilled  water, 

1000        c.c. 

qt.  i. 

Ringer's  formula: 

Potassium  chlorid, 

0.25  gm. 

gr.  iv. 

Calcium  chlorid, 

0.3    gm. 

gr.  4  1/2 

Sodium  chlorid, 

7         gm. 

dr.  I  2/3 

Distilled  water, 

1000        c.c. 

qt.  i. 

1  Fowler.     "The  Operating-room 

and  the  Patient." 



Locke  s  formula: 

Calcium  chlorid, 
Potassium  chlorid, 
Sodium  bicarbonate, 
Sodium  chlorid. 
Distilled  water, 

Szumann's  formula: 

Sodium  chlorid, 
Sodium  carbonate. 
Distilled  water 




gr.  HI. 




gr.  VI. 




gr.  4  1/2 



gr.  XV. 



dr.  2  1/4 

I  coo 


qt.  i. 



dr.  I  12 



gr.  XV. 

I  coo 


qt.  i. 


The  introduction  of  salt  solution  directly  into  a  vein  assures  us  of 
its  immediate  entrance  into  the  circulation  and  the  certainty  of  its 

Fig.   112. — Apparatus  for  giving  an  intravenous  infusion.     (Ashton.) 

absorption.  The  intravenous  method  is  thus  indicated  in  any  of  the 
conditions  previously  mentioned  where  there  is  necessity  for  great 
haste  and  a  prompt  response  to  the  treatment.  The  advantages  of 
this  method  of  infusion  are  pointed  out  by  Matas  as  being  almost 
unrestricted  in  possibilities  in  regard  to  quantity,  comparatively 
much  less  painful  than  the  subcutaneous  method,  and  requiring  the 
simplest  and  most  readily  improvised  apparatus. 



Apparatus. — There  should  be  provided  a  thermometer,  a  gradu- 
ated glass  irrigating  jar,  about  6  feet  (180  cm.)  of  rubber  tubing, 
1/4  inch  (6  mm.)  in  diameter,  and  a  blunt-pointed  metal  infusion 
cannula  (Fig.  112).  In  addition,  a  constrictor  for  the  arm,  a  gauze 
compress,  and  a  bandage  will  be  required. 

In  an  emergency,  a  fountain  syringe  or  a  large  funnel  will  answer 
for  the  reservoir,  and  the  glass  tube  of  a  medicine  dropper  will  take 
the  place  of  a  cannula. 

Instruments. — The  operator  will  require  a  scalpel,  a  pair  of  blunt- 
pointed  scissors,  mouse-toothed  thumb  forceps,  an  aneurysm  needle, 
a  needle  holder,  two  curved  needles  with  a  cutting  edge,  and  No.  2 
plain  catgut  (Fig.  113). 


i  ^^  o  ^  4 

Fig.   113. — Instruments     for     intravenous     infusion,      i, 
pointed    scissors;     3,    thumb   forceps;     4,    aneurysm    needle; 
curved  needles;  7,  No.  2  plain  catgut. 

Scalpel;  2,     blunt- 
5,    needle    holder;    6, 

Asepsis. — Strict  asepsis  should  be  observed.  The  instruments 
and  apparatus  should  be  boiled,  the  thermometer  should  be  immersed 
in  a  I  to  500  solution  of  bichlorid  of  mercury  for  ten  minutes,  and  then 
rinsed  in  sterile  water,  and  the  operator's  hands  should  be  as  carefully 
scrubbed  as  for  any  operation. 

Temperature  of  Solution. — Most  operators  advise  that  the  solu- 
tion be  administered  at  a  temperature  of  a  few  degrees  above  that 
of  normal  blood,  i.e.,  at  about  105°  F.  (41°  C).  The  stimulating 
effect  of  heat  upon  the  circulation,  however,  should  not  be  lost 
sight  of,  and,  when  such  an  action  is  desired,  the  solution  may  be 



used  at  a  tempearture  of  115°  to  118°  F.  (46°  to  48°  C.)  without 
harmful  effects.  It  should  be  borne  in  mind  that  there  will  be  some 
loss  of  heat  while  the  solution  is  flowing  from  the  reservoir.  For 
this  reason,  the  fluid  in  the  reservoir  should  be  kept  at  a  temperature 
of  from  2°  to  3°  higher  than  the  temperature  at  which  it  is  wished 
to  give  the  infusion. 

It  is  of  the  greatest  importance  that  the  solution  be  introduced 
into  the  body  at  a  uniform  temperature  throughout  the  entire  opera- 
tion. To  insure  this,  a  thermometer  is  kept 
in  the  solution  continuously.  By  watching 
the  thermometer  and  adding  hot  solution 
from  time  to  time,  as  that  in  the  reservoir 
cools,  a  uniform  temperature  may  be 

Rapidity  of  Flow. — The  speed  of  the 
flow  may  be  regulated  by  raising  or  lower- 
ing the  reservoir,  or  compressing  the  rub- 
ber tube.  The  rate  of  flow  should  be 
about  one  pint  (500  c.c.)  in  five  to  ten 
minutes.  It  should  be  remembered  that  the 
weaker  tJie  action  of  the  heart  the  slower  must 
the  fluid  be  introduced.  Acute  dilatation  of 
the  heart  may  be  produced  by  disregard  of 
this  caution.  Furthermore,  if  the  solution 
enters  the  circulation  too  rapidly,  the  fluid 
that  is  driven  from  the  heart  to  the  lungs 
may  consist  of  pure  salt  solution,  and  signs 
of  imperfect  oxygenation  of  the  blood  with 
embarrassed  respiration  and  restlessness  will 
follow.  If  such  symptoms  appear,  the  in- 
fusion must  be  discontinued  until  the  dan- 
gerous signs  have  passed. 

Quantity  Given. — It  has  been  shown  that  only  a  certain  amount  of 
the  solution  will  be  retained  in  the  circulation;  after  a  time  it  escapes 
into  the  tissues  and  produces  edema.  Hence  there  is  no  object  in 
infusing  enormous  quantities.  The  average  amount  administered 
at  a  time  varies  from  one  pint  (500  c.c.)  to  three  pints  (1500  c.c), 
depending  on  the  case,  but  larger  quantities  may  be  required  in  cases 
of  severe  hemorrhage,  or  after  venesection.  The  operator  will  be 
guided  as  to  the  requisite  quantity  chiefly  by  the  return  of  the  pulse, 
the  increase  in  its  volume,  and  by  the  improvement  in  the  color  of 

Fig.  114. — The  super- 
ficial veins  of  the  forearm. 



the  patient's  skin.  In  severe  cases  it  may  be  advisable  to  repeat  the 
infusion  two  or  three  times  within  twenty-four  hours  rather  than  to 
infuse  an  enormous  quantity  at  one  time. 

Site  of  Operation. — One  of  the  most  prominent  veins  at  the  bend 
of  the  elbow  is  usually  chosen  (Fig.  114),  preferably  the  median 
basilic  which  runs  across  the  bend  of  the  elbow  from  without  inward.^ 
At  times  a  vein  exposed  in  the  course  of  an  operation  may  be  con- 
veniently utilized. 

Preparation  of  the  Patient. — All  clothing  should  be  removed  from 
the  area  selected  for  the  infusion,  and  that  about  the  axilla  loosened 

Fig.   115. — Showing  the  application  of  the  bandage  to  the  arm  to  constrict   the 

veins,      (Ashton.) 

if  the  arm  is  chosen  for  the  infusion.  The  bend  of  the  elbow  is 
shaved,  if  necessary,  and  is  then  painted  with  tincture  of  iodin.  A 
sterile  bandage  is  tightly  wrapped  above  the  elbow  to  compress  the 
veins  and  make  them  more  prominent  (Fig.  115).  If  the  circulation 
is  very  feeble,  even  this  expedient  may  fail  to  make  the  veins  stand 
out  conspicuously. 

1  Dawbarn  advises  that  the  infusion  be  performed  through  the  internal  saphen- 
ous vein  at  a  point  anywhere  above  the  ankle,  claiming  (i)  that  it  is  as  large  or 
larger  than  the  veins  at  the  bend  of  the  elbow;  (2)  that  there  are  no  important 
structures  near  by  to  be  injured  by  a  careless  operator;  (3)  that  the  scar  is  unob- 
jectionable; and  (4)  that  the  assistants  performing  the  operation  will  usually 
interfere  less  with  the  operating  surgeon  than  if  the  arm  is  used. 



Anesthesia. — Anesthesia  of  the  skin  is  obtained  by  infiltration  at 
the  site  of  incision  with  a  0.2  per  cent,  solution  of  cocain  freshly 
prepared  or  a  i  per  cent,  solution  of  novocain,  or  by  freezing  with 
ethyl  chlorid  or  a  piece  of  ice  dipped  in  salt. 

Technic. — With  the  forearm  supinated,  a  transverse  incision  is 
made  over  the  median  basilic  vein  (Fig.  116).  The  vein  is  dissected 
from  its  bed  for  a  distance  of  i  to  i  1/2  inches  (2.5  to  4  cm.),  and  is 
raised  from  the  wound  while  two  catgut  ligatures  are  passed  beneath 
it  by  means  of  an  aneurysm  needle,  or,  in  its  absence,  by  a  pair  of 
thumb  forceps.  The  distal  portion  of  the  vein  is  tied  off  as  low  as 
possible  with  one  ligature,  and  the  second  ligature  is  placed  high  up 
around  the  portion  of  the  vein  nearest  the  heart,  ready  to  be  tied 
(Fig.  117).     A  portion  of  the  exposed  vein  is  now  grasped  in  a  mouse- 

FiG.   116. — Intravenous  saline  infusion.      (Ashton.)     First  step,  showing  the  vein 

exposed  by  a  small  incision. 

toothed  forceps  at  a  short  distance  from  the  distal  ligature,  and, 
while  the  vein  is  put  upon  the  stretch,  a  cut  directed  obliquely  up- 
ward is  made  with  scissors  through  half  the  vein,  exposing  its  lumen 
(Fig.  118).  The  solution  is  first  allowed  to  flow  through  the  cannula 
to  expel  any  air  or  fluid  that  may  have  become  cold  by  standing,  and 
the  cannula,  with  the  solution  still  flowing,  is  then  inserted  well  into 
the  cut  vein  (Fig.  119)  and  is  secured  in  place  by  tying  the  second 
ligature.  It  is  well  to  tie  this  ligature  in  a  bow  knot  so  that  it  may 
be  easilv  loosened  when  the  cannula  is  to  be  withdrawn  at  the  end  of 



the  operation  (Fig.  120).  The  bandage  is  now  removed  from  above 
the  elbow,  and  the  saline  solution  is  allowed  to  enter  the  circulation, 
the  reservoir  being  raised  2  to  6  feet  (60  to  180  cm.)  above  the  patient. 

Fig.  117. — Intravenous  saline  infusion.  Second  step,  showing  the  distal  end 
of  the  vein  tied  and  a  second  ligature  being  passed  under  the  proximal  end  of 
the  vein 

During  the  infusion  the  temperature  of  the  solution  must  be  kept 
uniform,  the  thermometer  in  the  reservoir  being  constantly  watched, 

Fig.  118.  Fig.  119. 

Fig.  118. — Intravenous  saline  infusion.  Third  step,  showing  the  method  of 
incising  the  vein. 

Fig.  119. — Intravenous  saline  infusion.  (Ashton.)  Fourth  step,  showing  the 
cannula  being  inserted  into  the  vein. 

and  care  must  be  taken  to  replenish  the  fluid  in  the  reservoir  bejore  it 
has  all  escaped,  otherwise  air  will  enter  the  vein  when  a  fresh  supply 
is  added. 



When  sufficient  solution  has  been  introduced,  the  ligature  about 
the  cannula  is  loosened,  and  the  latter  is  withdrawn.  With  this 
same  ligature  the  proximal  end  of  the  vein  may  be  then  tied  off 
(Fig.  i2i).  The  edges  of  the  skin  wound  are  united  with  several 
catgut  sutures,  and  a  sterile  gauze  dressing,  held  in  place  by  a  few 
turns  of  a  bandage,  is  applied. 

Variation  in  Technic. — Some  operators  perform  intravenous 
infusion  without  making  a  preliminary  incision  to  expose  the  vessel. 
The  same  apparatus  is  employed  as  for  an  ordinary  intravenous  infu- 

FiG.  1 20.  Fig,   121. 

Fig.  120. — Intravenous  saline  infusion.  Fifth  step,  showing  the  cannula  tied 
in  place. 

Fig.  121. — Intravenous  saline  infusion.  (Ashton.)  Sixth  step,  showing  the 
infusion  cannula  removed  and  the  proximal  end  of  the  vein  ligated. 

sion,  except  that  a  hypodermic  or  a  small  aspirating  needle  is  substi- 
tuted for  the  blunt  cannula.  The  needle,  with  the  solution  flowing, 
is  plunged  through  the  skin  directly  into  the  wall  of  the  vein. 

The  difficulty  in  placing  the  needle  accurately  in  the  vein,  espe- 
cially if  the  subject  is  very  fat,  places  a  limitation  upon  the  field 
of  usefulness  of  this  method. 


Saline  solution  may  be  injected  into  the  artery  instead  of  intra- 
venously, if  desired.  The  solution  may  be  injected  either  into  the 
distal  end  of  the  vessel,  or  into  the  proximal  end  against  the  blood 
current.  The  advantages  claimed  by  its  advocates  for  this  method 
of  infusion  over  the  venous  route  is  that  the  fluid,  being  first  driven 


to  the  capillaries,  is  sent  to  the  heart  more  gradually  and  is  more 
evenly  mixed  with  the  circulating  blood  than  when  the  entire  volume 
of  solution  enters  a  vein,  and,  as  a  result,  there  is  less  disturbance 
produced  in  the  circulation.  Infusion  against  the  blood  current  has, 
in  addition,  it  is  claimed,  a  stimulating  effect  upon  the  heart. 

These  alleged  advantages  of  arterial  infusion,  however,  seem  to 
be  overbalanced  by  the  accidents  that  may  follow  employment  of 
this  method,  there  having  been  reported  a  number  of  cases  in  which 
sloughing  about  the  area  of  infusion  resulted,  in  some  even  necessi- 
tating amputation  of  the  hand,  so  that  for  ordinary  purposes  saline 
solution  introduced  through  a  vein  should  be  the  method  of  choice. 

Crile  and  DoUey  {Journal  of  Experimental  Medicine,  Dec,  1906), 
however,  have  shown  that  the  infusion  of  normal  salt  solution  and 
adrenalin  into  an  artery  against  the  blood  current  is  suspended  ani- 
mation from  the  effects  of  anesthesia  or  other  causes  is  the  most 
effective  way  of  raising  the  blood-pressure  and  stimulating  the  heart. 
They  point  out  that  adrenalin  administered  by  the  venous  system 
comes  in  contact  with  vessels  having  the  least  power  of  influencing 
blood-pressure,  and  that  before  a  material  rise  can  be  effected  by  the 
action  of  the  adrenalin  upon  the  arteries  it  is  necessary  for  the  solu- 
tion to  pass  through  the  right  heart,  the  lungs,  and  then  back  to  the 
left  heart  before  it  reaches  the  aorta  and  coronary  arteries.  This 
often  causes  an  accumulation  of  solution  and  blood  in  the  dilated 
chambers  of  the  heart,  defeating  resuscitation.  On  the  other  hand, 
by  the  arterial  route,  the  blood  and  solution  are  driven  back  toward 
the  heart  directly  affecting  the  coronary  arteries,  thus  restoring 
blood-pressure  and  stimulating  the  heart  to  beat  again.  They  have 
shown  that  it  is  possible  by  this  method  to  resuscitate  animals  that 
were  apparently  dead. 

Apparatus. — The  same  apparatus  described  on  page  139  for  intra- 
venous infusion,  or  an  infusion  cannula  attached  to  a  large  glass 
funnel  by  a  piece  fo  rubber  tubing,  may  be  employed.  In  addition, 
a  hypodermic  syringe  will  be  required. 

Site  of  Infusion. — The  carotid  artery  or  one  of  its  large  branches 
is  chosen  for  the  injection  as  being  the  most  direct  route  to  the 
coronary  arteries. 

Technic. — Crile  {Am.  Jour,  of  Med.  Sciences,  April,  1909)  gives 
the  following  technic  for  employing  arterial  infusion  in  humans  for 
purposes  of  resuscitation.  "The  patient,  in  the  prone  position,  is 
subjected  at  once  to  rapid  rhythmic  pressure  upon  the  chest,  with 
one  hand  on  each  side  of  the  sternum.     This  pressure  produces 



artificial  respiration  and  a  moderate  artificial  circulation.  A  can- 
nula is  inserted  toward  the  heart  into  an  artery.  Normal  saline, 
Ringer's  or  Locke's  solution,  or,  in  their  absence,  sterile  water,  or,  in 
extremity,  even  tap  water  is  infused  by  means  of  a  funnel  and  rubber 
tubing.  But  as  soon  as  the  flow  has  begun  the  rubber  tubing  near 
the  cannula  is  pierced  with  a  hypodermic  syringe  loaded  with  i  to 
1000  adrenalin  chlorid  and  15  to  3oTn,  (i  to  2  c.c.)  are  at  once  in- 
jected. Repeat  the  injection  in  a  minute,  if  needed.  Synchro- 
nously with  the  injection  of  the  adrenalin,  the  rhythmic  pressure  on 
the  thorax  is  brought  to  a  maximum.  The  resulting  artificial  cir- 
culation distributes  the  adrenalin  that  spreads  its  stimulating  contact 

Fig.   122. — ^Showing  the  method  of  infusing  salt  and  adrenalin  solution  into  the 
carotid  artery.      (After  Da  Costa.) 

with  the  arteries,  bringing  a  wave  of  powerful  contraction  and  pro- 
ducing a  rising  arterial,  hence  coronary,  pressure.  When  the  coro- 
nary pressure  rises  to,  say,  40  mm.  or  more,  the  heart  is  liable  to 
spring  into  action.  The  first  result  of  such  action  is  to  spread  still 
further  the  blood-pressure-raising  adrenalin,  causing  a  further  and 
vigorous  rise  in  blood-pressure,  possibly  even  doubling  the  normal." 
.  .  .  "Just  as  soon  as  the  heart-beat  is  established,  the  cannula 
should  be  withdrawn,  first,  because  it  is  no  longer  needed,  and,  second 
the  rising  blood-pressure  will  drive  a  current  of  blood  into  the  tube 
and  funnel." 

Dawbarn's  Emergency  Method  of  Intraarterial  Infusion. — 
This  consists  in  injecting  saline  solution  into  the  circulation  through  a 



hypodermic,  or  a  long  line  aspirating  needle,  inserted  into  the  com- 
mon femoral  artery.  Dawbarn  recommends  it  as  an  emergency 
method  in  the  absence  of  cannula  and  instruments  necessary  for  in- 

PiG.   123. — Apparatus  for  infusing  salt  solution  into  an  artery  in    Dawbarn's 

emergency  method. 

travenous  infusion,  or  where  the  superficial  veins  are  small  and  very 
difficult  to  locate. 

Apparatus. — A  hypodermic  needle,  or  a  long  fine  aspirating 
needle,  and  an  ordinary  Davidson  syringe  (Fig.  123)  are  all  that  are 

Fig.   124. — Showing  the  method  of  infusing  salt  solution  into  the  femoral  artery. 

Technic. — The  femoral  artery  is  first  carefully  defined  just 
below  Poupart's  ligament.  The  aspirating  needle  is  then  forced  by 
a  slow  rotary  movement  directly  into  the  artery,  entering  it  at  right 
angles.     As  soon  as  the  needle  enters  the  vessel,  bright  red  blood 



will  fill  its  lumen.  The  rubber  tubing  of  the  syringe,  which  has  been 
previously  filled  with  saline  fluid,  is  then  slipped  over  the  base  of  the 
needle  and  is  firmly  secured  in  place  by  tying.  The  fluid  is  then 
steadily  pumped  from  a  basin  directly  into  the  arterial  circulation 
(Fig.  124).  According  to  Dawbarn,  it  requires  about  half  an  hour  to 
inject  a  pint  (500  c.c.)  of  solution  by  this  method.  If  a  fountain 
syringe  is  used  instead  of  a  Davidson  syringe,  it  must  be  held  at 
least  6  feet  (180  cm.)  above  the  patient  to  secure  the  necessary 
pressure,  otherwise  the  blood  will  be  forced  back  up  the  tube. 


The  subcutaneous  method  of  infusion  does  not  permit  as  rapid 
an  introduction  of  large  quantities  of  solution  as  the  intravenous, 

Fig.   125. — Apparatus  for  giving  hypodermoclysis.     (Ashton.) 

on  account  of  the  slowness  with  which  the  solution  is  absorbed.  It 
is  indicated  in  the  same  conditions  as  venous  infusions,  when  urgency 
is  not  of  prime  importance.  It  is  also  frequently  used  as  an  adjunct 
to  intravenous  infusion.  Hypodermoclysis  is  contraindicated  where 
the  tissues  are  edematous  from  dropsy,  or  where  the  circulation  is 
so  feeble  that  absorption  of  the  solution  is  very  slow  or  impossible. 
Apparatus. — There  will  be  required  a  thermometer,  a  graduated 
glass,  irrigating  jar,  6  feet  (180  cm.)  of  rubber  tubing,  1/4  inch  (6 
mm.)  in  diameter,  and  an  aspirating  needle  of  fair  size  (Fig.  125). 
When  it  is  desired  to  introduce  the  fluid  under  both  breasts  at  once, 


two  needles  fastened  to  the  rubber  tubing  by  means  of  a  Y-shaped 
glass  connection,  as  shown  in  Fig.  126,  may  be  employed. 

In  an  emergency,  a  glass  funnel  or  a  fountain  syringe,  to  which  is 
attached  an  ordinary  hypodermic  needle  by  several  feet  of  rubber 
tubing,  may  be  utilized. 

Asepsis. — The  necessary  apparatus  should  be  boiled,  the  seat  of 
injection  painted  with  tincture  of  iodin,  and  the  operator's  hands 
carefully  cleansed.  The  thermometer  is  sterilized  by  immersion  in 
a  I  to  500  bichlorid  solution  for  ten  minutes,  followed  by  rinsing  in 
sterile  water. 

Temperature  of  the  Solution. — The  solution  should  enter  the  body 
at  about  110°  F.  (43°  C).  When  using  a  large  aspirating  needle  the 
fluid  in  the  reservoir  should  be  kept  at  a  constant  temperature  of 
about  3  degrees  higher.  If  a  h^'podermic  needle  be  employed,  about 
5  degrees  should  be  allowed  for  cooling. 

Rapidity  of  Flow. — As  the  fluid  is  taken  up  with  comparative 
slowness  from  the  subcutaneous  tissues,  the  injection  is  given  less 
rapidly  than  by  the  intravenous  method.     With  a  fair-sized  needle 

Fig.   126. — Showing  two  needles  arranged  for  hypodermoclysis. 

about  a  pint  (500  c.c.)  of  fluid  may  be  injected  in  from  twenty  to 
thirty  minutes,  the  reservoir  being  held  from  3  to  4  feet  (90  to  120 
cm.)  above  the  patient.  W^hen  a  hypodermic  needle  is  employed, 
the  needle  being  so  small  in  caHber,  it  will  be  necessary  to  raise  the 
reservoir  5  or  6  feet  (150  to  180  cm.)  to  get  sufiicient  force. 

Quantity  Given. — Injections  of  small  quantities  of  solution,  re- 
peated several  times,  give  better  results  than  a  single  large  injection. 
As  a  rule,  from  8  to  16  ounces  (250  to  500  c.c.)  of  solution  are  intro- 
duced at  a  single  injection,  and  repeated  in  a  few  hours,  if  necessary. 
According  to  Hildebrand,  it  is  not  safe  to  introduce  a  larger  quantity 
of  solution  in  fifteen  minutes  than  i  dram  (4  c.c.)  to  each  pound 
(453  gm.)  of  body  weight.  If  this  ratio  is  exceeded,  the  fluid  accu- 
mulates and  the  tissues  become  water-logged,  as  the  kidneys  do  not 
secrete  rapidly  enough  to  carry  it  off.  Furthermore,  very  large 
quantities  of  solution  should  not  be  injected  into  one  area,  as  it  may 



produce  undue  distention  of  the  tissues  and  consequent  sloughing 
from  the  prolonged  anemia. 

Sites  of  Injection. — The  area  chosen  for  the  injection  should  be 
in  a  region  free  from  large  blood-vessels  and  nerves  and  where  there 

Fig.   127. — Sites  for  hypodermoclysis. 

is  an  abundance  of  loose  connective  tissue.  The  usual  sites  are: 
(i)  under  the  mammary  glands;  (2)  in  the  subcutaneous  tissue  be- 
tween the  crest  of  the  ilium  and  the  last  rib;  (3)  in  the  subcutaneous 
tissue  in  the  axillary  space;  (4)  in  the  subcutaneous  tissue  on  the  inner 
surfaces  of  the  thighs  (Fig.  127). 

Fig.   128. — Giving  hypodermoclysis  under  the  left  breast.      (Ashton.) 

Anesthesia. — The  point  of  skin  puncture  may  be  anesthetized  by 
the  injection  of  a  drop  or  tw^o  of  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  solution  of  novocain,  or  by  freezing  with  ethyl  chlorid 
or  salt  and  ice. 


Technic. — The  reservoir  is  raised  from  3  to  4  feet  (90  to  120  cm.) 
above  the  patient,  and  some  of  the  fluid  is  allowed  to  escape  from  the 
needle,  to  expel  any  air  or  cold  solution.  With  the  solution  still 
flowing,  the  operator,  using  steady  pressure,  inserts  the  needle  ob- 
liquely well  into  the  subcutaneous  tissue.  As  the  solution  enters,  a 
swelling  appears  in  the  subcutaneous  tissues  which,  however,  slowly 
subsides  as  the  fluid  is  absorbed  (Fig.  128).  If,  as  soon  as  the  tissues 
in  one  area  become  distended,  the  needle  be  partly  withdrawn  and 
its  direction  be  changed  shghtly,  a  large  amount  of  solution  may  be 
infiltrated  over  a  wide  area  without  producing  too  great  tension  at 
any  one  spot.  The  absorption  of  the  solution  may  be  hastened  by 
gentle  massage  over  the  infiltrated  area.  During  the  operation,  the 
temperature  of  the  solution  is  to  be  kept  uniform,  and  sufficient 
solution  must  be  in  the  reservoir  at  all  times  to  prevent  air  from 
entering  the  tube. 

When  the  desired  quantity  of  solution  has  been  introduced,  the 
needle  is  withdrawn  and  the  finger  is  placed  over  the  puncture  to  pre- 
vent the  escape  of  fluid.  The  puncture  is  then  sealed  with  sterile 
cotton  and  collodion. 

RECTAL  INFUSION.     (See  page  554.) 




This  is  a  small  operation  which  consists  in  the  insertion  of  needles 
or  other  small  sharp  instruments  either  into  the  superficial  tissues  for 
the  purpose  of  relieving  the  tension  in  swollen  or  edematous  areas,  or 
directly  into  muscles  or  nerves  for  the  relief  of  the  pain  of  muscular 
rheumatism  or  of  neuritis. 

For  the  relief  of  tension,  and  to  furnish  an  exit  for  the  effusion 
beneath  the  skin,  acupuncture  is  frequently  employed  in  edema 
involving  the  extremities,  labia,  or  scrotum,  though,  if  the  tissues  are 
so  greatly  distended  that  sloughing  seems  imminent,  incisions  should 
be  substituted  for  the  punctures.  In  acute  epididymitis  and  similar 
cases  acupuncture  is  also  often  used  with  good  results. 

Of  the  second  class  of  cases  it  is  employed  with  greatest  success 
in  lumbago  and  sciatica.  Just  how  acupuncture  acts  in  such  cases  is 
not  clear;  relief  of  pain  is  not  invariably  afforded,  for  in  some  cases  it 
seems  to  have  no  effect,  but  at  any  rate  the  method  is  worthy  of 
trial,  especially  before  more  severe  forms  of  treatment,  as  nerve 
stretching,  etc.,  are  instituted. 

Instruments. — To  relieve  tension,  the  pun,ctures  may  be  made 
with  triangular-pointed  surgeon's  needles  or  with  a  very  narrow- 

FiG.   129. — Instruments  for  acupuncture. 

bladed  bistoury  (Fig.  129).  Employed  for  the  relief  of  the  pain  of 
muscular  rheumatism  or  neuritis,  half  a  dozen  cyhndrical  needles 
about  3  or  4  inches  (7.5  to  10  cm.)  long  will  be  required.  Long  darn- 
ing needles  or  sharp  hat  pins  will  answer  very  well. 

Asepsis. — The  skin  should  be  sterilized  by  painting  the  sites  of 
puncture  with  tincture  of  iodin;  the  instruments  are  to  be  boiled; 
and  the  operator's  hands  are  cleansed  as  for  any  operation.  It  is 
especially  important  to  observe  all  aseptic  precautions  both  during 
and  after  puncture  of  dropsical  effusions,  as  the  tissues  in  such  cases 
have  poor  resistance  and  are  a  good  soil  for  infection. 



Anesthesia. — There  is  but  little  pain  connected  with  this  opera- 
tion, but  if  desired  the  skin  at  the  sites  of  puncture  may  be  frozen  with 
ethyl  chlorid. 

Technic. — Puncture  for  the  relief  of  tension  simply  consists  in 
making  a  single  or,  when  required,  numerous  deep  stabs  with  the 
needle  or  bistoury  into  the  swollen  area,  avoiding  injury  to  important 
vessels  or  nerves.  This  allows  the  escape  of  serum  which  may  be 
encouraged  by  the  application  of  moist  heat  in  the  form  of  dressings 
saturated  with  some  mild  antiseptic,  as  boric  acid. 

When  treating  muscular  rheumatism  by  this  method,  several 
sharp  round  needles  are  thrust  through  the  skin  into  the  painful  parts 
of  the  affected  muscle  to  a  depth  of  i  to  i  1/2  inches  (2.5  to  4  cm.), 
or  more,  depending  on  the  amount  of  adipose  tissue,  and  are  allowed 
to  remain  in  place  five  to  ten  minutes.  In  removing  them,  care  must 
be  taken  not  to  break  them  off  in  the  tissues.  Not  infrequently  the 
relief  of  pain  is  immediate. 

Applied  to  a  nerve,  the  same  technic  is  employed.  An  endeavor 
is  made  to  transfix  the  affected  nerve  with  from  four  to  six  needles 
along  the  painful  part  of  its  course.  It  may  sometimes  be  difficult 
to  strike  some  of  the  smaller  nerves,  but  with  a  large  nerve  like  the 
sciatic  there  is  usually  no  trouble.  The  patient's  sensations  will  be  a 
guide  as  to  whether  the  nerve  is  reached,  for,  as  soon  as  this  occurs, 
a  sharp  pain  will  be  felt  different  from  that  experienced  as  the  needle 
passes  through  the  superficial  tissues.  The  needles  when  properly 
placed  should  be  left  in  site  about  five  or  ten  minutes. 


The  operation  of  venesection,  or  phlebotomy,  consists  in  the  open- 
ing of  some  superficial  vein  and  the  abstraction  of  blood  from  the 
general  circulation  for  therapeutic  purposes. 

The  beneficial  effects  of  bleeding  have  been  recognized  from  the 
time  of  Hippocrates.  Unfortunately,  though,  bleeding  was  formerly 
much  overdone,  and  in  the  early  part  of  the  last  century  it  came  to  be 
the  custom  to  bleed  indiscriminately  for  almost  any  sickness.  In 
consequence  of  its  abuse  this  valuable  operation  has  lost  much  of  its 
popularity  and  is  now  but  rarely  practised.  Popular  prejudice, 
furthermore,  often  prevents  its  employment,  so  that  even  in  cases 
where  it  is  of  undoubted  therapeutic  value  the  practitioner  of  to-day 
prefers  to  put  his  trust  in  drugs  to  accomplish  the  desired  effects. 
In  spite  of  this  neglect,  bleeding  is  a  powerful  and  beneficial  thera- 
peutic measure  when  employed  in  the  proper  class  of  cases,  and,  as 



Hare  points  out,  "  the  indications  for  venesection  are  as  clear  and  well 
defined  as  are  the  indications  for  any  remedy." 

Indications. — These  may  be  better  appreciated  by  an  understand- 
ing of  what  venesection  accomplishes.  In  the  first  place,  through 
the  mechanical  effect  upon  the  circulation  of  removal  of  a  quantity 
of  blood,  the  tension  in  the  blood-vessels  is  diminished,  and  the  vas- 
cular tone  becomes  more  evenly  balanced,  so  that  an  engorged  area, 
where  the  vessels  are  relaxed  and  dilated,  is  relieved.  At  the  same 
time  the  speed  of  the  circulating  blood  in  the  capillaries  is  accelerated, 
and  stasis  is  further  prevented,  and  the  absorption  of  exudates 

Upon  the  general  system  venesection  also  has  beneficial  effects 
causing  a  lessened  activity  of  the  various  functions;  the  cardiac  and 

Fig.    130. — Instruments    for    venesection,      i,  Glass   graduate;  2,    ethyl    chlorid; 
3,  scalpel;  4,  stick  for  patient  to  grasp;  5,  bandages. 

respiratory  actions  become  less  active,  the  temperature  is  lowered, 
and  cell  proliferation  is  diminished. 

In  general,  then,  it  may  be  said  that  venesection  is  indicated  for 
the  relief  of  congestion  in  cases  of  excessive  vascular  tension  evidenced 
by  a  rapid,  strong,  full,  incompressible  pulse,  while  low  arterial  ten- 
sion and  circulatory  depression  with  a  slow,  soft,  irregular,  and  com- 
pressible pulse  are,  as  a  rule,  contraindications.  Thus  in  sthenic 
t)^es  of  croupous  pneumonia  with  dilated  right  heart,  dyspnea,  and 
cyanosis,  in  pleurisy,  peritonitis,  pulmonary  edema,  pulmonary 
hemorrhage,  emphysema  with  marked  dyspnea  and  cyanosis,  conges- 
tion of  the  brain,  cardiac  valvular  disease  with  engorged  right  heart, 
bleeding  both  lowers  vascular  tension  and  relieves  engorgement.  In 
cases  where  toxins  or  other  deleterious  substances  are  present  in  the 



blood,  as  in  eclampsia,  uremic  convulsions,  illuminating-gas  poison- 
ing, poisoning  by  hydrogen  sulphid,  prussic  acid,  etc.,  bleeding  serves 
the  double  purpose  of  reducing  arterial  tension  and  removing  a  defi- 
nite quantity  of  toxic  material.  Large  quantities  of  blood  may  be 
abstracted  in  such  cases,  followed  by  transfusion  or  saline  infusion 
(the  so-called  "blood  washing")  with  unquestionably  good  results. 

Instruments. — There  will  be  required  a 
scalpel  or  bistoury,  a  sterile  gauze  pad, 
several  bandages,  a  round  object  as  a  stick 
or  roller  bandage  for  the  patient  to  grasp, 
and  a  large  glass  graduate  (Fig.  130). 

Quantity  Withdrawn. — On  an  average 
from  6  ounces  (180  c.c.)  to  15  ounces  (450 
c.c.)  may  be  abstracted  from  an  adult,  and 
from  I  ounce  (30  c.c.)  to  3  ounces  (90  c.c.) 
from  a  child,  depending  on  the  condition 
and  the  character  of  the  pulse  and  upon  the 
appearance  of  the  patient.  This  amount 
may  be  increased,  hov/ever.  if  the  venesection 
is  to  be  supplemented  by  transfusion  or 
saline  infusion.  Under  such  conditions  20 
ounces  (600  c.c.)  or  more  may  be  removed 
from  an  adult. 

Site  of  Operation. — Some  one  of  the 
large  veins  in  front  of  the  elbow-joint  is 
usually  selected  (Fig.  131).  but  the  internal 
jugular  or  internal  saphenous  may  be 

Position  of  the  Patient. — The  patient  should  be  sitting  upright  or 
in  a  semirecHning  position  on  a  couch,  with  his  head  turned  away 
from  the  seat  of  operation,  as  the  sight  of  blood  may  cause  faintness. 
The  semiupright  position  is  a  safeguard  against  withdrawing  too 
much  blood,  as  the  patient  becomes  faint  sooner  than  if  he  were  lying 

Asepsis. — While  this  is  a  small  operation,  at  the  same  time  all 
aseptic  precautions  should  be  observed.  In  former  times  many 
patients  lost  their  lives  from  septic  thrombosis.  Accordingly,  the 
instruments  and  dressings  should  be  sterile,  and  the  hands  of  the 
operator  should  be  as  carefully  prepared  as  for  any  operation.  The 
bend  of  the  patient's  elbow  is  first  shaved  if  necessary  and  is  then 
painted  with  tincture  of  iodin. 

Fig.  131. — Superficial 
veins  of  the  forearm. 



Anesthesia. — The  area  of  incision  may  be  anesthetized  by  infil- 
trating with  a  few  drops  of  a  0.2  per  cent,  solution  of  cocain  or  a  i 
per  cent,  novocain  solution,  or  by  freezing  with  ethyl  chlorid  or  salt 
and  ice. 

Technic. — A  few  turns  of  a  roller  bandage  are  placed  about  the 
patient's  arm  above  the  elbow  with  just  sufficient  tension  to  obstruct 
the  venous  circulation  and  make  the  veins  stand  out  prominently 
(Fig.  132).  By  directing  the  patient  to  grasp  some  object  and  work 
his  fingers  while  the  arm  is  hanging  down,  the  veins  will  become  even 
more  distended.  The  patient's  arm  is  then  placed  in  an  extended  and 
abducted  position.     The  operator  next  identifies  either  the  median 

Fig.   132. — Venesection.      First  step,  showing  the  application  of  the  bandage  to 

the  arm.      (Ashton.) 

basilic  or  median  cephalic  vein,  and,  compressing  it  with  his  left 
thumb  placed  just  below  the  seat  of  incision,  makes  a  small  cut  trans- 
versely to  the  long  axis  of  the  vein  (Fig.  133),  which  is  exposed  by 
dissection  and  a  small  opening  made  in  its  anterior  wall  (Fig.  134). 
The  arm  is  then  turned  over,  the  thumb  removed,  and  the  blood  is 
permitted  to  escape  into  a  glass  graduate  (Fig.  135). 

While  cutting  down  on  the  vein  care  must  be  taken  not  to  disturb 
the  relative  positions  of  the  skin  and  vein  by  drawing  on  the  skin, 
otherwise  the  cut  through  the  skin  and  that  into  the  vein  will  not 
coincide  when  the  finger  is  removed  and  the  skin  released,  with  the 



result  that  the  blood  will  escape  under  the  skin  into  the  subcutaneous 
tissues.     If  the  median  basilic  vein  is  utilized,  the  incision  into  its 

Fig.  133.  Fig.   134. 

Fig.   133. — Venesection.     Second    step,   vein   exposed   and    operator's    finger 
compressing  the  distal  portion  of  the  vessel. 

Fig.  134. — Venesection.     Third  step,  showing  incision  into  vein  walls. 

Fig.   135. — Venesection.     Fourth  step,  showing  the  operator's  finger  removed  from 
the  vein  and  the  blood  being  collected  in  a  glass  graduate. 

wall  must  not  be  made  too  deeply  for  fear  of  wounding  the  brachial 


When  a  sufficient  quantity  of  blood  has  been  abstracted,  a  gauze 
pad  is  held  over  the  wound  by  the  thumb,  and  the  bandage  is  removed 
from  the  arm.  The  incision  is  then  dressed  with  a  sterile  gauze 
compress  held  in  place  by  a  bandage.  If  simple  compression  is  not 
sufficient  to  stop  the  breeding,  both  ends  of  the  vein  should  be  sought 
and  ligated  with  fine  catgut.  The  patient  should  be  instructed  to 
carry  the  arm  in  a  sling  for  a  few  days  following  this  operation. 

Complications. — The  most  serious  complication  is  a  puncture  of 
the  brachial  artery  by  the  incision  into  the  vein  producing  an  arterio- 
venous aneurysm.  This  may  be  avoided  by  carefully  cutting  down 
upon  the  vein  and  not  incising  skin,  superficial  tissues,  and  vein  at 
one  cut. 

Sometimes  a  very  painful  neuralgia  is  a  sequel  to  the  operation, 
probably  due  to  injury  to  some  of  the  cutaneous  nerves  of  the  region. 
If  the  instruments  are  clean  and  proper  aseptic  precautions  are 
observed,  septic  thrombosis  is  not  to  be  feared. 

Variations  in  Technic. — Some  operators  extract  the  blood  by 
means  of  a  medium  sized  aspirating  needle  attached  to  a  large 
antitoxin  syringe  or  through  a  vein  trocar  to  which  is  attached  a  piece 
of  rubber  tubing  which  leads  to  a  glass  graduate.  The  needle  or  tro- 
car is  plunged  through  the  skin  into  the  vein  in  the  same  manner  as 
is  done  in  withdrawing  blood  for  bacteriological  examination  (see 
page  223). 


Scarification  consists  in  making  multiple  incisions  into  the  tissues 
for  the  relief  of  local  congestion  or  tension.  By  this  method  of  local 
bleeding,  engorged  blood-vessels  are  emptied  and  effusions  of  serum 
are  permitted  to  escape;  thus  undue  tension  from  exudates  is  relieved, 
and  the  tendency  of  the  tissues  to  slough  is  lessened. 

For  the  relief  of  inflammatory  conditions  of  the  skin  and  mucous 
membranes  scarification  finds  its  chief  apphcation.  Thus  in  inflamed 
ulcers,  threatened  gangrene  from  extreme  tension,  phlegmonous  ery- 
sipelas, etc.,  prompt  relief  often  follows  its  use.  Scarification  may 
also  be  employed  in  the  place  of  multiple  punctures  for  the  rehef  of 
tension  in  marked  edema  of  the  extremities,  labia,  and  scrotum. 
In  urinary  infiltration  deep  scarification  becomes  necessary  to  allow 
the  escape  of  the  extravasation  and  to  prevent  sloughing.  In  inflam- 
matory aff"ections  and  edemas  of  the  pharynx,  uvula,  tonsils,  and  glot- 
tis it  is  often  indicated;  in  involvement  of  the  latter  with  progressive 



dyspnea  and  cyanosis  the  scarification  should  be  performed  without 
any  delay. 

Instruments. — An  ordinary  scalpel  or  bistoury  is  all  that  is  neces- 

FiG.    136. — Automatic  scarificator. 

sary.  A  special  scarifier  (Fig.  136)  may  be  employed,  however,  if 
desired.  This  instrument  consists  of  a  metal  box  containing  a  num- 
ber of  sharp  blades,  which,  upon  touching  a  spring,  are  suddenly 

Fig.    137. — Knife  wrapped  with  adhesive  plaster. 

forced  out  in  such  a  way  as  to  cut  the  tissues  to  which  the  instrument 
is  applied  to  any  desired  depth. 

For  incising   the   tonsil,    glottis,    etc.,    a   sharp-pointed   curved, 
bistoury  wrapped  with  adhesive  plaster  to  within  1/4  inch  (6  mm.)  of 

Fig.    138. — Protected  laryngeal  knife. 

its  point  (Fig.  137)  should  be  employed  in  the  absence  of  a  protected 
laryngeal  knife  (Fig.  138). 

Asepsis. — The  operation  must  be  performed  with  all  the  usual 
aseptic  precautions. 



Anesthesia. — Where  extensive  incisions  are  required,  as  in  urinary 
extravasation,  for  example,  nitrous  oxid  anesthesia  will  be  required. 
In  other  cases  local  anesthesia  with  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  novocain  solution,  or  by  freezing,  if  the  nutrition  of 
the  parts  is  unimpaired,  will  suffice.  Mucous  surfaces  may  be  anes- 
thetized with  a  4  per  cent,  solution  of  cocain  sprayed  upon  or  applied 
directly  to  the  parts. 

Technic. — The  incisions  are  made  in  parallel  rows  over  the 
inflamed  area,  and,  according  to  the  indications,  they  may  or  may  not 
extend  through  the  entire  thickness  of  the  skin.  They  should  always 
be  made  in  the  long  axis  of  a  limb  (Fig.  139)  and  in  other  regions  paral- 
lel to  the  lines  of  cleavage,  care  being  taken  not  to  wound  the  super- 
ficial nerves  or  large  veins.  Warm  fomentations  applied  to  the  scar- 
ified area  assist  in  maintaining  the  escape  of  blood  and  serum. 

Fig.   139. — Showing  the  method  of  scarifying  a  Hmb. 

Scarification  of  the  larynx  is  performed  with  the  aid  of  laryngos- 
copy (page  389).  When  a  clear  view  of  the  edematous  parts  has 
been  obtained,  incisions  about  1/4  inch  (6  mm.)  in  length  are 
made  with  the  point  of  the  protected  bistoury  in  the  areas  of  most 
marked  swelling.  When  it  is  feasible,  these  incisions  are  made  on  the 
outer  surfaces  of  the  parts  to  avoid  having  blood  flow  into  the  larynx. 
A  gargle  of  hot  water  or  an  inhalation  of  steam  is  then  employed  to 
encourage  the  bleeding  and  escape  of  the  serum.  This  often  gives 
complete  relief  in  a  few  hours;  if  the  symptoms  are  not  improved, 
however,  or  the  dyspnea  recurs,  tracheotomy  (page  424)  must  be 
performed  without  hesitation. 


Three  operative  procedures  may  be  employed  for  reKeving  edema 
of  the  lower  extremities  when  the  tension  becomes  too  great,  namely. 



multiple  punctures  (page  152),  incision  (page  158),  and  drainage  by 
the  trocar  and  cannula.  Of  these,  the  latter  is  less  troublesome,  more 
cleanly,  and  certainly  far  more  comfortable  for  the  patient. 

From  one  to  four  cannulas  may  be  employed  at  a  time,  and  con- 
siderable fluid  may  be  drained  off  in  this  way.  When  more  than  one 
cannula  is  used  several  quarts  may  be  abstracted  in  twenty-four 
hours,  but  the  operator  should  be  cautious  about  withdrawing  too 
great  a  quantity  for  fear  of  inducing  a  condition  of  cerebral  anemia. 
Should  such  a  condition  be  produced,  the  drainage  should,  of  course, 
be  immediately  stopped  and  stimulants  administered. 

Fig.  140. — Southey's  trocars  and  cannula. 

Apparatus. — Southey's  tubes  (Fig.  140)  or  those  of  Curschmann 
may  be  employed.  The  former  are  made  in  a  set  consisting  of  one 
trocar  and  four  cannulae.  Each  cannula  has  lateral  openings  as  well 
as  a  distal  opening.  The  lumen  of  the  cannula  is  about  1/25  inch 
(i  mm.)  in  diameter.  In  addition,  pieces  of  rubber  tubing  about 3  feet 
(90  cm.)  long  to  lead  from  the  tubes  to  receptacles  are  required. 

Sites  of  Puncture. — The  back  or  outer  sides  of  the  legs  are  usually 

Asepsis. — Rigid  asepsis  should  be  observed  to  avoid  infection. 
The  trocar  and  cannula  are  boiled,  the  operator's  hands  carefully 
cleansed,  and  the  spot  chosen  for  puncture  is  first  shaved  and  then 
painted  with  tincture  of  iodin. 



Technic. — One  cannula  at  a  time  is  placed  on  the  trocar  and  is 
inserted  an  inch  (2.5  cm.)  or  more  into  the  subcutaneous  tissues  at 
right  angles  to  the  surface.  The  trocar  is  then  removed  and  to  the 
free  end  of  the  cannula  is  attached  a  rubber  tube  idled  with  some 
antiseptic  solution.  The  distal  end  of  the  tube  is  allowed  to  drain  into 
a  basin  placed  upon  the  floor  by  the  side  of  the  patient's  bed  (Fig. 
141).  Three  or  more  cannulae  are  introduced  in  this  manner.  The 
cannulse  should  be  secured  in  place  by  means  of  adhesive  plaster,  and 
sterilized  dressings  should  be  placed  about  them.     Elevation  of  the 

Fig.   141. — Showing  the  method  of  draining  an  edematous  limb  with  Southey's 
cannula.      (After  Gumprecht.) 

head  of  the  bed  from  6  to  24  inches  (15  to  60  cm.)  allows  the  fluid  to 
gravitate  to  the  extremities  and  is  of  considerable  help  when  the 
edema  is  generalized.  Care  should  be  taken  that  the  cannula?  are  not 
displaced,  and  for  this  reason,  with  restless  patients,  it  is  better  to 
remove  them  at  night.  It  is  preferable  in  any  case  to  make  new 
punctures  than  to  leave  the  cannulae  in  place  for  several  days.  After 
removal  of  the  cannulae,  the  sites  of  the  punctures  should  be  sealed 
with  collodion  and  cotton. 


Cupping  may  be  either  dry  or  wet  according  to  the  method  of 
application.  Dry  cupping  produces  a  local  congestion  of  the  super- 
ficial tissues  and  relieves  congestion  of  the  deeper  .subjacent  organs 



by  deviating  the  blood  from  these  parts.  Wet  cupping,  in  addition, 
actually  abstracts  blood  from  the  tissues.  Cupping  finds  its  chief 
appKcation  in  the  relief  of  congestion  of  deeply  placed  organs  as  the 
brain,  spinal  cord,  lungs,  liver,  kidneys,  etc. 

Apparatus. — Special  cupping  glasses  supplied  with  a  rubber  bulb 
for  exhausting  the  air  (Fig.  142)  are  obtainable  and  will  be  found  very 

Fig.   142. — Bulb  form  of  cupping  glass. 

convenient,  but  the  ordinary  cupping  glasses  in  which  the  vacuum  is 
created  by  igniting  a  httle  alcohol  smeared  over  the  interior  of  the  cup 
are  just  as  efficient.  In  an  emergency,  2-ounce  (60  c.c.)  whisky  or 
wineglasses,  or  thick  tumblers  with  smooth  rounded  edges  will  answer 

Fig.   143. — Instruments  for  wet  cupping,      i,  Cupping  glasses;  2,  swab  in  alcohol; 
3,  alcohol  lamp;  4,  scalpel. 

equally  well.  From  8  to  1 2  cups  will  be  required  in  dry  cupping  and 
from  2  to  6  in  wet  cupping,  depending  upon  the  extent  of  surface  to 
which  they  are  to  be  applied. 

In  addition  to  the  cups  there  should  be  provided  some  alcohol,  a 
small  stick  to  the  end  of  which  a  cotton  swab  is  attached,  and  matches 



or  an  alcohol  flame.     If  wet  cupping  is  to  be  employed,  there  will 
also  be  required  a  sharp  scalpel  or  lancet  (Fig.  143). 

Sites  of  Application. — Cupping  glasses  are  never  to  be  applied 
directly  over  inflamed  tissues  on  account  of  the  pain  that  would 
result.     Nor  should  they  be  placed  over  bon}'  or  irregular  surfaces  on 

Fig.   144. — Cupping.     First  step,  swabbing  the  interior  of  the  cupping  glass  with 


account  of  the  impossibility  of  excluding  air.  Where  the  brain  is  the 
seat  of  the  trouble,  the  cups  are  applied  to  the  back  of  the  neck;  in 
pericarditis,  to  the  precordial  region;  in  involvement  of  the  lungs  or 
pleura,  to  the  chest  between  the  vertebral  column  and  scapular  line; 

Fig.   145. — Cupping.     Second  step,  igniting  the  alcohol  in  the  cupping  glass. 

in  renal  congestion  or  acute  nephritis,  to  the  lumbar  regions;  in  affec- 
tions of  the  eye,  to  the  temples;  etc.  Wet  cups,  however,  are  often 
followed  by  scarring,  hence  they  should  not  be  applied  over  conspicu- 
ous regions  or  upon  the  shoulders  or  chests  of  women. 



Technic. — i.  Dry  Cupping. — Any  hair  should  be  first  shaved  off 
the  part  and  the  surface  of  the  skin  dampened  with  warm  water  so 
that  the  cups  will  adhere.  To  apply  caps  supplied  with  an  exhausting 
bulb,  simply  compress  the  rubber  bulb,  then  place  the  cup  upon  the 
skin,  and  release  the  bulb.  A  partial  vacuum  is  thus  produced  and 
the  skin  and  underlying  tissues  engorged  with  blood  are  sucked  up 
into  the  cup. 

When  ordinary  cups  are  employed,  the  swab,  saturated  with 
alcohol,  is  lightly  wiped  over  the  interior  of  each  cup  (Fig.  144), 
care  being  taken  not  to  leave  any  excess  of  alcohol  that  may  run  down 


Cupping.     Third  step,  the  application  of  the  cups. 

over  the  edges.  The  alcohol  is  then  ignited  (Fig.  145),  and  the  cup  is 
quickly  and  tightly  applied  to  the  skin.  The  contained  air  is  rapidly 
exhausted  by  the  flame,  and,  as  the  cup  cools,  a  strong  vacuum  is 
created,  which  draws  up  the  underlying  tissues  (Fig.  146))  and  pro- 
duces local  congestion.  A  number  of  cups — anywhere  from  eight  to 
ten — may  be  applied  in  the  same  manner  over  any  given  region.  If 
the  cups  are  air-tight,  the  flame  is  extinguished  before  the  patient 
feels  the  heat  from  the  burning  alcohol.  When  the  swelling  of  the 
skin  and  underlying  tissues  has  taken  place  to  such  an  extent  as  to 
replace  the  exhausted  air,  the  cups  become  loosened  and  drop  off. 
If,  however,  it  is  desired  to  remove  the  cups  before  this  has  occurred, 
simply  tip  the  cup  to  one  side  and  press  down  the  skin  at  the  edge  of 
the  glass  and  thus  allow  air  to  enter. 


2.  Wet  Cupping. — By  this  method  a  definite  amount  of  blood 
may  be  removed,  each  cup  being  capable  of  abstracting  from  i  to  3 
drams  (4  to  12  c.c).  The  cups  are  first  applied  to  the  region  as  already 
described;  then  with  a  scalpel  parallel  incisions  about  1/3  inch 
(8.5  mm.)  apart  are  made,  care  being  taken  to  incise  the  skin  only, 
for,  if  the  subcutaneous  tissues  are  cut  into,  particles  of  fat  will  be 
drawn  up  into  the  cuts  when  the  cups  are  reappHed.  The  cups  are 
then  immediately  applied  for  the  second  time.  Blood  will  be  drawn 
from  the  scarified  area  into  the  cups  until  the  vacuum  is  exhausted 
and  the  cups  fall  oflf.  If  it  is  desired  to  withdraw  more  blood,  the 
cups  are  emptied  and,  after  washing  away  the  clots  from  the  cut  sur- 
face, they  are  applied  again,  or  hot  fomentations  may  be  employed  to 
encourage  the  bleeding.  When  sufficient  blood  has  been  withdrawn, 
a  sterile  gauze  dressing  is  applied  over  the  scarified  region. 


Leeching  may  be  employed  for  the  purpose  of  abstracting  blood 
from  contused  or  congested  areas  inaccessible  to  wet  cupping.  It  is 
thus  a  valuable  means  of  local  blood-letting  in  ecchymoses,  or  begin- 
ning acute  inflammation  about  the  eye,  ear,  nose,  gums,  genitals,  etc. 

There  are  two  varieties  of  leech  used  for  this  purpose:  the  small 
American  leech  which  is  capable  of  withdrawing  about  a  dram  (4 
c.c.)  of  blood  and  the  Sweedish  leech  which  will  suck  from  3  to  4 
drams  (4  to  15  c.c).  According  to  the  amount  of  blood  it  is  desired 
to  remove,  from  one  to  six  leeches  may  be  applied  at  one  time.  Only 
those  coming  from  clean,  uncontaminated  water  should  be  used. 

Sites  of  Application. — It  should  be  remembered  that  the  leech 
produces  a  triangular  cut  in  the  skin  which  results  in  a  permanent 
scar,  hence  they  should  not  be  placed  upon  conspicuous  portions  of 
the  body.  They  should  never  be  applied  to  regions  where  there  is 
much  loose  cellular  tissue,  such  as  the  eyelids,  labia,  scrotum,  or  penis, 
for  extensive  ecchymoses  may  be  the  result.  As  their  bite  is  irritat- 
ing, they  should  not  be  applied  directly  to  an  inflamed  area;  instead, 
they  are  to  be  applied  to  the  periphery.  They  should  never  be 
allowed  to  take  hold  of  the  skin  directly  over  a  superficial  artery, 
vein,  or  nerve. 

Leeches  are  generally  applied  to  the  temples  or  the  back  of  the 
neck  in  congestion  or  inflammation  of  the  brain,  to  the  mastoid  and 
in  front  of  the  tragus  in  acute  mastoiditis  and  acute  otitis  media,  to 
the  perineum   when  the  scrotum,  penis,  or  labia  are  the  regions 


alTected,  and  to  the  coccyx  for  the  rehef  of  congested  or  inflamed 

Asepsis. — To  avoid  infection  the  skin  over  the  region  to  which  the 
leech  is  appHed  should  be  washed  with  soap  and  water.  If  the  part  is 
hairy,  it  should  be  first  shaved. 

Technic. — The  leech  is  applied  to  the  part  and  confined  under 
a  pill-box  or  wineglass  until  it  takes  hold.  A  special  leech-tube  or  a 
test-tube  may  be  employed  for  this  purpose,  in  which  case  the  leech 
is  placed  in  the  tube  tail  or  large  end  first  and  the  tube  is  then 
inverted  so  that  the  leech's  head  comes  in  contact  with  the  skin. 
This  may  be  removed  as  soon  as  the  leech  takes  hold,  but,  in  employ- 
ing leeches  about  the  orifices  of  mucous  cavities,  they  should  always  be 
confined  so  as  to  prevent  their  escape  into  the  interior.  If  the 
leeches  are  removed  from  the  water  an  hour  or  so  before  using,  they 
will  take  hold  more  readily.  Making  a  puncture  in  the  skin  and 
applying  the  leech  to  the  bleeding  spot  or  rubbing  the  skin  with 
sweetened  water  or  milk  will  cause  the  leech  to  take  hold,  if  it  does  not 
seem  inclined  to  do  so.  When  once  the  leech  has  begun  to  draw 
blood,  it  should  not  be  pulled  off — it  will  drop  off  when  filled.  If  it  is 
desirable,  however,  to  remove  it. sooner,  sprinkling  salt  over  it  will 
induce  it  to  let  go. 

By  applying  hot  fomentations  to  the  part  after  the  removal  of 
the  leech  bleeding  can  be  encouraged  and  often  an  ounce  (30  c.c.)  or 
more  of  blood  may  be  withdrawn  in  this  way.  After  removal  of  the 
leech  the  bite  should  be  bathed  with  sterile  water  and  a  small  gauze 
dressing  applied. 

Sometimes  a  considerable  and  troublesome  bleeding  continues 
from  the  leech  bite,  due  to  the  fact  that  the  tissues  become  infiltrated 
with  material  excreted  from  the  throat  of  the  leech  which  prevents 
coagulation  of  the  blood.  The  bleeding  can  usually  be  controlled, 
however,  by  compression  or  by  applying  a  piece  of  cotton  saturated 
with  some  styptic,  as  a  solution  of  i  to  1000  adrenalin  chlorid,  alum, 
or  tannic  acid.  The  use  of  the  actual  cautery  or  passing  a  harelip 
pin  or  needle  beneath  the  bite  and  winding  a  thread  about  the  two 
ends  so  as  to  constrict  the  part  are  also  advised.  Failing  in  these 
measures,  the  bite  should  be  excised  and  the  tissues  sutured. 

The  Artificial  Leech. — This  apparatus  may  be  employed  instead 
of  live  leeches.  It  consists  of  a  small  cupping  apparatus  combined 
with  a  scarifier  (Fig.  147).  The  latter  is  in  the  form  of  a  small  steel 
cylinder  containing  a  circular  lancet  propelled  by  a  cord  or  a  spring. 
The  skin  is  first  scarified,  by  drawing  upon  the  cord  which  causes  the 


Fig.  147. — Artificial  leech. 

Fig.   148. — Application  of  the  artificial  leech  to  the  mastoid.      (After  Ballenger.) 
First  step,  showing  the  method  of  scarifj'^ing. 

Fig.   149. — Apphcation  of  the  artificial  leech  to  the  mastoid.      (After  Ballenger.) 
Second  step,  withdrawing  blood. 


lancet  to  rapidly  rotate,  as  shown  in  the  accompanying  illustration 
(Fig.  148),  the  blades  of  the  instrument  being  adjusted  so  as  to  cut  to 
the  desired  depth.  Then  the  cupping  tube  is  apphed  and  blood 
abstracted  by  withdrawing  the  piston  and  creating  a  vacuum  (Fig. 
149) .  With  this  instrument  as  much  as  i  ounce  (30  c.c.)  of  blood  may 
be  withdrawn. 





Drugs  may  be  administered  by  injection  into  the  subcutaneous  or 
muscular  tissues  when  a  rapid  effect  is  desired,  or  when,  for  any 
reason,  medication  by  the  mouth  is  undesirable  or  is  contraindicated. 
The  injection  of  soluble,  nonirritating  substances  is  made  into  the 
subcutaneous  tissues,  from  which  the  absorption  is  very  rapid;  but 
when  the  solution  is  insoluble  or  irritating,  so  that  its  presence 
in  sensitive  tissues  would  produce  pain,  it  had  best  be  given 

The  advantages  of  hypodermic  medication,  besides  the  prompt- 
ness of  the  effects  obtained,  consist  in  aft'ording  a  method  whereby 
it  is  possible  to  administer  remedies  in  the  presence  of  nausea  and 
vomiting,  or  inability  or  unwillingness  on  the  part  of  the  patient  to 
swallow;  furthermore,  the  absorption  of  the  drug  is  not  dependent 
upon  the  functional  activity  of  the  gastrointestinal  tract. 

The  Hypodermic  Syringe. — The  ordinary  hypodermic  syringe 
consists  of  a  glass  barrel  protected  by  a  metal  case  and  furnished  with 

Fig.    150. — -Ordinary  glass  and  metal  hypodermic  syringe. 

a  leather-covered  piston  (Fig.  150).  Such  syringes,  however,  are 
difficult  to  keep  clean  and,  if  they  are  frequently  boiled,  the  leather 
packing  soon  dries  out  and  becomes  inefficient  unless  carefully  at- 
tended to.  Syringes  of  solid  metal  (Fig.  151)  or  those  consisting  of 
a  glass  barrel  and  soHd  glass  piston,  as  the  Luer  (Fig.  152),  or  with 
an  asbestos-covered  piston,  as  the  "Sub-Q,"  will  be  found  preferable. 



and  may  be  easily  cleaned  and  repeatedly  boiled  without  harm.  A 
syringe  with  a  capacity  of  3oTn,  (2  c.c.)  is  amply  large  for  ordinary 

The  needles  should  be  as  tine  as  possible  (28  to  27  gauge)  and 
very  sharp,  and  for  injection  beneath  the  skin  they  should  be  about 
I  inch  (2.5  cm.)  in  length.  For  the  administration  of  liquids  of  a 
heavy  consistency  a  needle  of  somewhat  larger  caliber  will  be  required. 
For  intramuscular  injections,  the  needle  should  be  i  1/2  to  2  inches 
(4  to  5  cm.)  long,  and,  if  one  of  the  insoluble  preparations  of  mercury 
is  employed,   the  caliber  of  the  needle  should  be  correspondingly 

Fig.    151. — All  metal  hypodermic  syringe. 

large.  To  prevent  the  needles  rusting  and  the  lumen  becoming 
plugged,  they  should  be  first  well  cleaned  out  with  water  after  using, 
followed  by  alcohol  and  ether  to  remove  any  remaining  fluid  from  the 
interior  that  might  cause  rusting,  and,  finally,  they  should  be  put 
away  with  a  fine  wire  inserted  in  the  lumen. 

Preparation  of  the  Solution. — The  drugs  most  frequently  used  for 
hypodermic  medication  are  morphin,  atropin,  strychnin,  hyoscin, 
pilocarpin,  cafi'ein,  cocain,  apomorphin,  quinin,  mercury,  digitalis, 
ergotin,  nitroglycerin,  adrenalin,  alcohol,  ether,  etc.     As  the  majority 

Fig.   152. — Luer's  hypodermic  syringe. 

of  these  are  either  very  powerful  or  poisonous,  the  dose  should  be 
accurately  measured  in  every  case. 

The  solution  employed  for  the  injection  should  always  be  sterile 
and  preferably  freshly  prepared.  The  strength  of  the  solution  is  also 
important,  for,  if  too  concentrated,  it  may  prove  irritating,  while, 
if  greatly  diluted,  the  bulk  of  solution  necessary  for  the  injection 
becomes  objectionable.  Most  of  the  drugs  for  hypodermic  use  may 
be  obtained  in  the  form  of  soluble  tablets  which  are  dissolved  in  5 
to  icTtl  (o-3  to  0.6  c.c.)  of  boiled  water  when  required  for  use.  Sterile 
solutions  of  the  drugs,  however,  may  be  obtained  in  hermetically 



sealed  glass  ampoules,  each  containing  suflScient  for  one  dose.  The 
solution  must  be  as  nearly  neutral  as  possible;  irritating  solutions  or 
strongly  alcoholic  preparations  should  be  avoided  on  account  of  the 
danger  of  subsequent  sloughing  at  the  seat  of  injection.  When 
whisky  or  brandy  is  employed,  it  is,  therefore,  well  to  dilute  them 
with  an  equal  amount  of  water  before  using.  Insoluble  preparations, 
as  the  salicylate  of  mercury,  for  example,  are  best  administered  in 
some  sterile  oil  as  albolene  or  benzoinol. 

Sites  for  Injection. — For  ordinary  injections  the  least  sensitive 
portions  of  the  body  provided  with  plenty  of  cellular  tissue  are 

Fig.   153. — Sites  for  hypodermic  injections. 

selected,  the  spot  chosen,  of  course,  being  distant  from  the  immediate 
neighborhood  of  large  blood-vessels  or  nerves,  bony  prominences,  or 
inflamed  areas.  The  common  sites  are  the  outer  surfaces  of  the  arm, 
forearm,  thighs,  or  the  buttocks. 

For  deep  intramuscular  injections  of  drugs  not  rapidly  absorbed 
an  area  in  the  gluteal  region,  lying  between  the  gluteal  fold  below  and 
a  horizontal  line  through  the  upper  margin  of  the  great  trochanter, 
is  usually  chosen  (Fig.  153).  Where  numerous  injections  are  given 
care  should  be  taken  to  alternate  between  the  two  sides  and  to  avoid 


repeating  the  injections  in  the  same  spot  each  time.  Meltzer 
{Medical  Record,  March  25,  191 1)  recommends  that  intramuscular 
injections  be  made  in  the  lumbar  muscles,  claiming  that  absorption 
is  more  rapid  than  from  the  glutei.  The  spot  chosen  is  at  the  junc- 
tion of  the  inner  and  middle  thirds  of  a  line  uniting  the  highest 

Fig.   154. — Showing  the  method  of  giving  a  hypodermic  injection. 

points  of  the  iliac  crest  with  the  third  or  fourth  lumbar  spinous 

Position  of  Patient. — For  a  deep  intramuscular  injection  the 
patient  lies  upon  the  opposite  side  or  upon  the  abdomen. 

Asepsis. — The  strictest  regard  as  to  cleanliness  should  always 
be  observed.     The  needle  and  syringe  should  be  boiled  or  at  least 

Fig.   155. — Deep  intramuscular  injection.     First  step,  inserting  the  needle. 

immersed  in  some  antiseptic  solution  before  use,  and  the  skin  at 
the  site  of  the  injection  should  be  painted  with  tincture  of  iodin  or 
rubbed  clean  with  a  piece  of  cotton  or  gauze  saturated  with  alcohol. 
Technic.^ — The  required  amount  of  solution  is  drawn  into  the 
barrel  of  the  syringe  with  the  needle  in  place  and  any  air  is  expelled 
by  elevating  the  needle  end  and  depressing  the  piston.     The  skin 



over  the  site  of  the  proposed  injection  is  then  pinched  up  between 
the  thumb  and  forefinger  of  the  left  hand,  while  with  the  right  hand 
the  needle  is  quickly  thrust  at  an  angle  of  45  degrees  into  the  sub- 

FiG.   156. — Deep    intramuscular    injection.     Second    step,    showing    the     syringe 
removed  and  inspection  of  the  needle  for  the  flow  of  blood. 

cutaneous  tissues  at  the  base  of  this  fold  (Fig.  154).  If  the  needle 
is  sharp  and  it  be  quickly  plunged  through  the  skin,  but  little,  if  any, 
pain  will  be  experienced.  The  solution  should  be  injected  slowly  to 
avoid  too  sudden  distention  of   the   tissues.     When  the   required 

Fig.   157. — Deep  intramuscular  injection.     Third  step,  injecting  the  solution. 

amount  has  been  introduced,  the  needle  is  quickly  withdrawn,  and 
the  finger  is  placed  over  the  site  of  puncture,  and  gentle  massage  is 
practised  for  a  moment  or  two  to  diffuse  the  solution. 


In  giving  a  deep  intramuscular  injection,  the  skin  over  the  chosen 
site  is  held  tense  by  the  fingers  of  the  left  hand,  and  the  needle  is 
steadily  forced  through  the  skin  and  subcutaneous  tissues  directly 
into  the  glutei  muscles  up  to  its  hilt  (Fig.  155).  As  soon  as  the  needle 
is  in  place,  it  is  advisable  to  remove  the  syringe  and  observe  whether 
there  is  any  flow  of  blood  from  the  needle  (Fig.  156);  if  so,  a  new 
puncture  should  be  made.  Observance  of  this  precaution  will 
obviate  injecting  the  solution  into  the  blood  current  should  the  needle 
point  penetrate  some  vein.  The  solution  is  then  injected  slowly 
(Fig.  157),  and  at  the  completion  of  the  operation  the  site  of  punc- 
ture is  sealed  with  collodion  or  by  means  of  a  small  piece  of  adhesive 



Salvarsan,  or  "606,"  is  a  yellowish  crystalline  powder  containing 
about  1/3  of  its  weight  of  arsenic.  It  was  introduced  by  Ehrlich 
in  1 9 10  for  the  cure  of  syphilis  after  years  of  experimental  work 
upon  animals  with  spirillicidal  drugs.  Although  salvarsan  has 
proved  a  most  important  addition  to  therapeutics,  we  have 
been  compelled  to  revise  materially  our  early  conceptions  of  its 
value.  It  was  originally  claimed  that  one  large  dose  would  entirely 
destroy  the  spirochetes  of  syphilis,  but  unfortunately  this  early  prom- 
ise has  not  been  realized  in  the  majority  of  cases.  There  is  no 
doubt  that  this  new  remedy  is  a  powerful  spirochetal  poison  and  it 
unquestionably  causes  certain  of  the  manifestations  of  syphilis  to 
disappear  very  rapidly,  but  whether  the  results  obtained  from  its 
use,  even  in  repeated  doses,  are  permanent  or  only  temporary  will 
require  many  years  to  establish.  Owing  to  numerous  relapses  that 
have  followed  single  injections,  it  is  now  generally  agreed  that  a  single 
dose  is  not  curative.  At  the  present  time,  the  majority  of  authori- 
ties advise  that  the  injection  should  be  repeated  one  or  more  times 
and  that  its  use  should  be  followed  by  the  administration  of  mercury 
for  the  usual  period. 

Salvarsan  is  indicated  in  all  stages  of  syphilis.  It  gives  the  best 
results,  however,  the  earlier  in  the  disease  it  is  used,  being  more 
rapidly  effective  than  mercury,  especially  upon  mucous  lesions,  and 
causing  the  Wassermann  reaction  to  become  more  quickly  negative. 
So  that  in  the  primary  and  early  secondary  stages  the  most  brilliant 


results  are  obtained,  while  in  the  late  secondary  and  tertiary  stages 
it  becomes  more  difficult  to  eradicate  the  infection.  It  has  little  or 
no  effect  in  well  marked  locomotor  ataxia  and  paresis.^  It  is  contra- 
indicated  in  advanced  degenerative  processes  of  the  central  nervous 
system  and  in  long-standing  cardiac  and  vascular  degenerations, 
and  in  nonsyphilitic  retinal  and  optic  nerve  afTections.  Syphilitic 
eye  and  ear  diseases,  however,  are  not  contraindications  to  its  use. 
Any  known  idiosyncrasy  against  arsenic  should  lead  to  great  caution 
in  its  use. 

Salvarsan  has  also  been  employed  in  the  treatment  of  other  diseases 
due  to  spirilla  with  excellent  results.  In  relapsing  fever,  filariasis,  yaws, 
and  in  some  forms  of  malaria,  it  has  proved  very  efficacious,  frequently 
one  injection  sufficing  to  produce  a  cure.  It  has  also  been  tried  in 
leukemia,  splenic  anemia,  leprosy,  tuberculosis,  and  pellagra  with 
questionable  results.  In  certain  of  the  infectious  diseases  in  which 
it  has  been  used,  as  scarlet  fever,  small-pox,  anthrax,  glanders,  it  is 
too  early  to  give  a  positive  opinion  as  to  its  value. 

Salvarsan  was  at  first  given  subcutaneously.  Then  intramus- 
cular injections  were  substituted,  but  these  proved  very  painful. 
The  drug  was  not  always  absorbed,  and  at  times  caused  great  irri- 
tation at  the  site  of  injection  and,  in  some  cases,  sloughs  that  were 
very  slow  in  separating.  At  the  present  time  the  intravenous 
method  of  administration  is  generally  adopted. 

Its  administration  is  likely  to  be  followed  in  from  one  to  six  hours 
by  a  systemic  reaction,  consisting  of  a  chill,  a  rise  of  i  to  2  degrees  in 
the  temperature,  gastric  irritation,  and  diarrhoea.  These  symptoms, 
however,  are  not  always  present,  and  the  temperature  and  chill  are 
less  likely  to  occur  if  freshly  distilled  water  is  used  in  the  preparation 
of  the  solution.  In  exceptional  cases,  following  an  injection,  or  as 
late  as  one  or  two  days  after,  the  patient  becomes  quite  sick;  he  has 

1  Recently,  Swift  and  Ellis  of  the  Rockefeller  Institute  have  developed  a  new 
line  of  treatment  for  syphilis  of  the  central  nervous  system,  employing  intra- 
spinous  injections  of  salvarsanized  serum.  The  results  in  the  cases  so  far 
reported  have  been  most  encouraging,  and  it  would  seem  that  in  some  cases  of 
tabes  and  paresis  a  cure  may  be  effected  and  even  in  well-marked  cases  the 
disease  may  be  checked  by  the  intraspinous  serum  treatment. 

The  technic  is  briefly  as  follows:  Salvarsan  is  given  intravenously,  usually  in  a 
maximum  dose,  and  an  hour  later  10  drams  (40  c  c.)  of  blood  are  withdrawn  from 
the  patient  by  venous  puncture  into  a  bottle-shaped  centrifuge  tube.  This  is 
allowed  to  coagulate,  after  which  it  is  centrifuged.  The  next  day  3  drams 
(12  c.c.)  of  the  resulting  clear  serum  are  removed  by  means  of  a  pipette, 
mixed  with  5  drams  (18  c.c.)  of  sterile  normal  salt  solution,  and  heated  for  half 
an  hour  at  a  temperature  of  132.8°  F.  (56°  C).  This  serum  is  then  injected  by 
lumbar  puncture,  after  withdrawing  a  small  quantity  of  the  cerebrospinal  fluid. 



headache,    vertigo,    severe    gastric    irritation,    high    temperature, 
loose  stools,  and  disturbance  of  circulation.    A  transient  albumi- 
nuria may  be  present  during  elimination  of  the  drug.     In  some  cases 
death  has  resulted  with  all  the  symptoms  of  arsenical  poisoning. 
Apparatus. — There  will  be  required  (i)  a  graduated  glass  cylinder 


Fig.  158. — Apparatus  for  intravenous  injection  of  salvarsan.  i,  Graduated 
reservoir,  rubber  tubing,  and  vein  needle;  2,  graduate  and  glass  rod  for  mixing 
the  solution;  3,  decanter  for  distilled  water;  4,  glass  funnel;  5,  medicine  dropper; 
6,  bottle  of  sodium  hydroxid  solution;  7,  tube  of  salvarsan;  8,  file;  9,  catheter  for 
constricting  arm;   10,  artery  clamp, 

with  a  capacity  of  about  10  ounces  (300  cc),  (2)  4  feet  (120  cm.)  of 
rubber  tubing  with  a  short  piece  of  glass  tube  inserted  in  it  to  allow 
detection  of  any  air  bubbles,  (3)  a  Schreiber  infusion  needle,  2  1/2 
inches (6  cm.)  long  and  of  No.  18  caliber,  (4)  a  glass  decanter  for  dis- 
tilled water,  (5)  a  glass  graduate  for  mixing  the  solution,  (6)  a  funnel 

Fig,   159. — Enlarged  view  of  vein  needle, 

in  which  is  placed  filter  paper  or  sterile  cotton  to  filter  the  solution 
through,  (7)  a  glass  stoppered  bottle  containing  a  solution  of  15  per 
cent,  sodium  hydroxid,  (8)  a  medicine  dropper,  (9)  a  glass  stirring 
rod,  (10)  a  catheter  and  artery  clamp  for  constricting  the  arm  of  the 
patient,  (11)  a  tube  of  salvarsan  and  a  file  to  open  it  with  (Fig,  158). 


In  addition,  it  is  well  to  have  at  hand  a  scalpel  and  a  cocain 
syringe  in  case  it  is  necessary  to  expose  the  vein  before  inserting  the 

Asepsis. — The  apparatus  is  sterilized  by  boiling.  The  tube  con- 
taining the  salvarsan  and  the  file  are  placed  in  alcohol,  and  the 
operator's  hands  are  prepared  as  carefully  as  for  any  operation. 

Preparation  of  the  Solution. — It  has  been  found  that  much  of 
the  immediate  systemic  reaction  is  due  to  impurities  in  the  water, 
for  this  reason  only  freshly  distilled  sterile  water  should  be  employed 
in  the  preparation  of  the  solution.  The  ampoule  of  salvarsan 
is  dried  off,  the  glass  is  nicked  with  the  file,  the  tube  is  broken 
open,  and  its  contents  are  poured  into  30  to  40  c.c.  (i  to  i  1/2 
ounces)  of  hot  sterile  distilled  water  previously  placed  in  the 
mixing  glass.  The  solution  is  then  shaken  or  stirred  until  all  the  drug 
is  thoroughly  dissolved.  To  the  resulting  clear  acid  solution  is 
added  drop  by  drop  the  15  per  cent,  sodium  hydroxid  solution  b\- 
means  of  the  dropper,  the  solution  being  shaken  after  each  drop  is 
added.  This  causes  a  precipitate  to  form,  which  dissolves  as  the 
solution  becomes  alkaline.  It  requires  about  20  drops  of  the  sodium 
hydroxid  solution  to  render  a  mixture  containing  0.5  gm.  (7  1/2 
gr.)  of  salvarsan  perfectly  clear.  Having  obtained  an  absolutely 
clear  solution,  it  is  diluted  with  sterile  0.5  per  cent,  saline  solution, 
made  from  chemically  pure  sodium  chlorid  and  sterile,  freshly  distilled 
water,  up  to  250  c.c.  (8  ounces)  if,  for  example,  0.5  gm.  (7  1/2  gr.) 
is  the  dose,  that  is,  50  c.c.  (i  2/7,  ounces)  of  fluid  is  used  for  every 
0.1  gm.  (i  1/2  gr.)  of  salvarsan.  The  solution  is  now  ready  for  use 
and  is  finally  filtered  through  sterile  cotton  placed  in  a  funnel  into 
the  intravenous  apparatus. 

Temperature  of  the  Solution. — The  solution  is  given  at  about  a 
temperature  of  105°  F.  (41°  C). 

Dosage. — An  average  dose  for  men  is  0,4  to  0.5  gm.  (6  to  7  1/2 
gr.),  for  women  0.3  to  0.4  gm.  (4  1/2  to  6  gr.),  for  children  0.2  to 
0.3  gm.  (3  to  4  1/2  gr.),  and  for  infants  0.02  to  0.05  gm.  (1/3  to  3/4 
gr.).  In  this  country  it  is  becoming  customary  to  employ  smaller 
initial  doses,  that  is,  0.2  and  0.3  gm.  (3  and  4  1/2  gr.)  doses  and,  if 
no  unpleasant  symptoms  follow,  the  second  dose  may  be  increased 
0.1  gm.  (i  1/2  gr.). 

Repetition  of  the  Dose. — The  injection  may  be  repeated  in  from 
one  to  four  weeks,  depending  upon  the  reaction  produced  and  the 
effect  on  the  lesions.     In  the  early  cases  from  three  to  four  injections 


are  usually  given,  and  in  the  late  cases  from  five  to  six,  or  more,  un- 
til the  Wassermann  reaction  remains  negative. 

Site  of  Injection. — Some  one  of  the  prominent  veins  on  the 
anterior  aspect  of  the  arm  in  front  of  the  elbow-joint — preferably 
the  median  basilic — is  chosen  for  the  injection. 

Position  of  the  Patient. — The  injection  should  be  given  with  the 
patient  in  the  recumbent  posture. 

Preparations  of  Patient. — All  tight  clothing  should  be  removed 
from  the  arm  selected  for  the  infusion.  The  site  of  puncture  is 
painted  with  tincture  of  iodin,  and  the  rubber  catheter  is  secured 
about  the  arm  with  sufficient  tension  to  make  the  veins  stand  out 

Technic. — With  the  tourniquet  properly  apphed  about  the  fore- 
arm, the  operator  identifies  the  vein  into  which  he  wishes  to  insert 
the  needle  and  instructs   the  patient   to  work  his  fingers  until  the 

Fig.   160. —  ■Method  of  inserting  needle  into  the  vein. 

vein  becomes  quite  prominent.  The  needle,  held  almost  flat  with 
the  skin  surface,  is  then  thrust  through  the  skin  into  the  vein  toward 
the  axilla  (Fig.  i6o).  The  successful  entrance  into  the  vein  is  indi- 
cated by  a  flow  of  blood  from  the  end  of  the  needle.  Care  must  be 
taken  to  insert  the  needle  into  the  vein  and  not  through  the  opposite 
wall  of  the  vein.  If  the  needle  is  held  almost  parallel  with  the  sur- 
face of  the  arm,  this  accident  is  not  likely  to  occur.  If  there  is  any 
difficulty  in  finding  the  vein,  it  should  be  exposed  by  a  small  trans- 
verse nick  through  the  skin  under  infiltration  anesthesia  and  the 
needle  inserted  by  sight.  The  tourniquet  is  then  removed  from  the 
patient's  arm,  and,  after  seeing  that  all  the  air  is  expelled  from 
the  tubing  of  the  intravenous  apparatus,  the  latter  is  connected 



with  the  needle,  and  the  solution  is  permitted  to  flow  into  the  vein. 
The  solution  is  injected  very  cautiously  at  first  until  it  is  certain 
that  it  is  entering  the  vein  and  not  the  surrounding  tissues,  or  a 
test  injection  of  a  small  amount  of  normal  salt  solution  is  made. 
Any  leakage  of  the  salvarsan  solution  into  the  tissues  causes 
a  severe  burning  pain  and  necessitates  the  immediate  stoppage  of 
the  injection.     During  the  injection  the  reservoir  is  raised  24  to 

Fig.   161. — Method  of  giving  salvarsan  intravenously. 

30  inches  (60  to  75  cm.)  above  the  level  of  the  patient.  It  takes 
about  ten  minutes  for  the  entire  quantity  of  solution  to  flow 
into  the  vein:  at  the  completion  of  the  operation  the  needle  is 
quickly  removed  and  a  sterile  pad  is  placed  over  the  site  of  puncture 
and  is  secured  by  a  few  turns  of  a  bandage. 

While  some  operators  administer  salvarsan  intravenously  in  their 
ofl5ce.  the  patient  being  required  to  go  home  immediately  and  remain 



quiet  for  several  hours,  there  is  considerable  risk  connected  with  such 
a  procedure,  and  it  is  safer  to  give  the  first  injection,  at  any  rate,  in 
the  patient's  home  or  at  a  hospital,  following  which  the  patient  is 
required  to  remain  quiet  in  bed  for  twelve  hours. 


Lately  a  new  and  very  soluble  form  of  salvarsan  has  been  intro- 
duced under  the  name  of  neosalvarsan,  or  "914."  The  general  prop- 
erties of  neosalvarsan  are  similar  to  those  of  salvarsan  and  it  is 
claimed  to  be  just  as  efficacious.  It,  however,  possesses  certain 
decided  advantages  over  salvarsan  in  that  it  is  better  tolerated  and 
is  less  often  followed  by  a  systemic  reaction,  so  that  larger  doses 
can  be  employed  and  the  dose  may  be  repeated  more  frequently. 
Furthermore,  the  preparation  of  the  solution  is  very  simple,  the  drug 
being  quite  soluble  in  water  and  not  requiring  to  be  neutralized  with 
caustic  soda, 

Neosalvarsan  is  given  intravenously  or  by  intramuscular  injec- 
tion— preferably  by  the  former  method. 

Apparatus. — For  the  intravenous  administration  of  dilute  solu- 
tions of  neosalvarsan  the  same  apparatus  described  for  the  adminis- 
tration of  salvarsan  (page  177)  will  be  required. 

1  K  3  » 

Fig.  162. — Apparatus  for  intramuscular  and  intravenous  injections  of  con- 
centrated solutions  of  neosalvarsan.  i,  Decanter  of  distilled  water;  2,  medicine 
glass;  3,  all  glass  syringe  and  needle;  4,  tube  of  neosalvarsan;  5,  small  file. 

For  the  intravenous  administration  of  concentrated  solutions  and 
for  intramuscular  injections  there  will  be  required:  (i)  a  Luer  or 
Record  syringe  with  a  capacity  of  10  to  20  c.c.  (2  1/2  to  5  dr.),  (2) 
a  needle  about  2  1/2  inches  (6  cm.)  long  and  of  No.  18  caliber,  (3)  a 
glass  decanter  for  distilled  water,  (4)  a  medicine  glass  for  mixing  the 
solution,  (5)  a  tube  of  neosalvarsan  and  a  file  to  open  it  with,  and 


(6)  a  glass  rod  for  stirring  (Fig.  162).  In  addition,  for  an  intra- 
venous injection  a  tourniquet  will  be  required  . 

Asepsis. — The  apparatus  and  instruments  are  sterilized  by 
boiling,  the  operator's  hands  are  cleansed  as  for  any  operation,  and 
the  tube  of  neosalvarsan  and  the  file  are  immersed  in  alcohol. 

Preparation  of  the  Solution. — For  intravenous  injections  a  dilute 
or  a  concentrated  solution  may  be  used.  The  former  is  prepared  by 
dissolving  each  0.15  gm.  (2  1/3  gr.)  of  salvarsan  in  25  c.c.  (6  3/4  dr.) 
of  freshly  distilled  sterile  water.  The  water  should  not  be  heated, 
but  should  be  at  about  the  temperature  of  the  room,  that  is,  68°  to 
71.6°  F.  (20°  to  22°  C). 

The  concentrated  intravenous  solution  is  prepared  by  dissolving 
0.45  to  0.6  gm.  (6  3/4  to  9  gr.)  of  neosalvarsan  in  10  c.c.  (2  3/4  dr.) 
of  freshly  distilled  sterile  water,  or  0.75  to  0.9  gm.  (11  1/2  to  14  gr.) 
of  neosalvarsan  in  15  c.c.  (4  dr.)  oi  freshly  distilled  sterile  water. 

The  solution  for  an  intramuscular  injection  is  prepared  by  dis- 
solving each  0.15  gm.  (2  1/3  gr.)  of  neosalvarsan  in  about  3  c.c. 
(48  minims)    of  freshly  distilled  sterile  water. 

Temperature  of  the  Solution. — The  solution  should  not  be  injected 
at  a  higher  temperature  than  68°  to  71.6°  F.  (  20°  to  22°  C). 

Dosage. — The  average  dose  of  neosalvarsan  for  men  is  0.6  to 
0.75  gm.  (9  to  II  1/2  gr.),  for  women  0.45  to  0.6  gm.  (6  3/4  to  9 
gr.),  for  children  0.15  to  0.3  gm.  (2  1/3  to  4  2/3  gr.),  and  for  infants 
0.05  gm.  (3/4  gr.). 

Repetition  of  the  Dose. — Injections  of  neosalvarsan  may  be 
repeated  at  intervals  of  from  3  to  7  days. 

Site  of  Injection. — Intravenous  injections  are  given  in  the  median 
basilic  or  some  other  prominent  vein  at  the  bend  of  the  elbow. 

Intramuscular  injections  are  given  in  the  gluteal  region  (see 
page  172). 

Position  of  Patient. — For  an  intravenous  injection  the  patient 
should  be  recumbent;  for  an  intramuscular  injection  the  patient 
lies  upon  the  abdomen. 

Preparation  of  the  Patient. — If  the  intravenous  method  is  em- 
ployed, all  constricting  clothing  should  be  removed  from  the  patient's 
arm.     The  site  of  puncture  is  well  painted  with  tincture  of  iodin. 

Technic. — (i)  Intravenous  Administration.  The  technic  differs 
in  no  material  way  from  that  already  described  for  the  administra- 
tion of  salvarsan  (see  page  179).  When  the  concentrated  solution 
is  employed,  however,  the  injection  is  more  conveniently  made  with 
a  syringe  instead  of  a  gravity  apparatus. 


(2)  Intramuscular  Injecti&n. — A  spot  in  the  gluteal  region  dis- 
tant from  the  course  of  the  sciatic  nerve  is  chosen,  and  the  needle  is 
thrust  deeply  into  the  muscle.  If  there  is  no  bleeding,  about  60 
drops  of  0.5  per  cent,  novocain  solution  is  injected  into  the  region  in 
order  to  diminish  the  sensibility.  Then,  after  waiting  a  few  moments, 
the  desired  quantity  of  neosalvarsan  is  injected  through  the  same 
needle.  The  site  of  puncture  is  finally  sealed  with  a  piece  of  adhesive 
plaster.  (The  technic  of  intramuscular  injections  is  more  fully 
described  on  page  175.)  Following  the  injection,  the  patient  is  kept 
in  the  recumbent  position  on  his  side  or  abdomen  for  15  to  20 


Antitoxin  is  now  almost  universally  used  in  the  treatment  of  diph- 
theria, and  its  administration  is  a  procedure  with  which  all  physicians 
should  be  familiar.  It  has  enormously  reduced  the  mortality  from 
this  disease,  and,  if  the  serum  is  of  reliable  quality,  its  use  is  without 
danger.  The  diphtheria  bacilli  are  not  killed  by  the  antitoxin,  but 
the  toxins  are  neutralized  and  a  condition  is  produced  in  the  blood 
which  inhibits  the  growth  of  the  bacilli  so  that  they  gradually  dis- 

The  Serum. — As  the  serum  is  liable  to  be  contaminated  it  should 
always  be  obtained  from  an  unquestionable  source.  Antitoxin  of 
the  greatest  concentration,  that  is,  containing  as  little  serum  and  as 
many  units^  of  antitoxin  as  is  possible,  should  be  used  in  preference, 
as  smaller  amounts  at  a  dose  will  be  required  and  joint  pains,  skin 
eruptions,  etc. — symptoms  which  are  now  considered  to  be  due  to  the 
horse  serum  and  not  the  antitoxin — will  be  avoided. 

Dosage. — There  is  no  definite  rule  for  fixing  the  dose.  It  is  known 
how  much  antitoxin  is  required  to  neutralize  a  given  amount  of  toxin, 
but  in  practice  there  is  no  method  of  estimating  the  latter  in  any  given 
case.  Conclusions  drawn  from  experience  and  clinical  studies  give 
the  only  practical  guides.  The  dose  should  always  be  large,  however, 
for  the  serum  is  harmless  and  it  is  better  to  administer  too  much  than 
not  enough.  The  average  dose  advised  by  the  New  York  Health 
Department  is  5000  units,  repeated  the  following  day  if  the  condition 
of  the  patient  has  not  improved.  According  to  Holt ''  for  a  child  over 
two  years,  an  initial  dose  for  a  severe  attack,  including  all  laryngeal 

^  The  strength  of  the  serum  is  measured  in  units,  a  unit  being  the  amount  of 
antitoxin  necessary  to  neutralize  in  a  guinea-pig  lOO  fatal  doses  of  diphtheria. 

1 84 


cases,  should  not  be  less  than  4000  to  5000  units;  and  the  dose  should 
be  repeated  in  six  or  eight  hours  provided  no  improvement  is  seen. 
Children  under  two  years  should  receive  from  2000  to  3000  units. 
Cases  of  exceptional  severity  where  the  injection  is  given  late  should 
receive  from  8000  to  10,000  units,  to  be  repeated  in  from  six  to  eight 
hours  if  the  progress  of  the  disease  is  unfavorable.  Mild  cases  should 
receive  from  2000  to  3000  units  as  an  initial  dose,  a  second  being  rarely 

An  immunizing  dose  should  be  given  to  those  exposed  to  the  con- 
tagion in  all  cases,  1000  units  for  a  child  under  two  years  old,  and  for 
older  children  and  adults  a  larger  dose  (2000  units)  may  be  adminis- 
tered. The  immunity  thus  furnished  is  not  permanent,  however, 
lasting  only  three  or  four  weeks. 

Time  of  Administration. — Antitoxin  should  be  given  as  soon  as  a 
clinical  diagnosis  is  made,  not  waiting  for  a  bacteriological  examina- 
tion. There  are  no  contraindications  to  its  use  in  the  presence  of 
urgent  symptoms.  No  matter  how  late  a  case  is  seen,  an  injection 
should  be  given,  though  it  may  not  be  possible  to  undo  the  harm 
already  produced  by  the  diphtheria  toxin.  Cases  treated  very  early 
give  the  best  results.  This  is  well  shown  by  the  following  table  of 
the  cases  injected  in  1902-4,  prepared  by  the  New  York  Health 


No.  cases. 

Case  fatality. 










3  and  4 




5  and  over 




The  Syringe. — The  simpler  the  syringe,  the  better.     The  syringe 
should  have  a  capacity  of  about  i  1/4  to  2  1/2  drams  (5  to  10  c.c). 

Fig.   163. — The  record  antitoxin  syringe. 

Glass  syringes  with  asbestos  packing  or  those  with  the  solid  glass 
piston,  as  the  Luer,  are  most  easily  sterilized.  The  record  syringe 
(Fig.  163)  is  also  an  excellent  instrument.  A  moderately  fine  needle 
or  the  smallest  through  which  the  serum  will  flow  is  preferable  to  one 



of  very  large  caliber.  In  charging  the  syringe  it  is  better  to  remove 
the  piston  and  pour  the  antitoxin  into  the  syringe,  as  it  is  difficult  to 
draw  it  up  through  the  needle.  The  piston  is  then  inserted  and,  with 
the  syringe  elevated,  any  air  is  expelled.  Many  of  the  manufac- 
turers at  the  present  time  Supply  a  syringe  already  sterilized  and  filled 
with  antitoxin  (Fig.  164).  The  advantages  of  this  in  the  saving  of 
time  are  obvious. 

Fig.  164. — -The  New  York  Board  of  Health  Antitoxin  Syringe.  The  syringe 
comes  steriHzed  and  already  loaded  with  antitoxin  and,  upon  inserting  the  needle 
into  the  distal  end,  is  ready  for  use. 

Site  of  Injection. — The  subcutaneous  tissues  of  the  outer  aspect 
of  the  thigh,  of  the  back  part  of  the  axilla,  or  of  the  upper  portion  of 
the  abdomen  are  usually  chosen  for  the  injection  (Fig.  165). 

Asepsis. — The  syringe  and  needles  should  always  be  sterilized  by 
a  thorough  boiling  before  use.  The  operator's  hands  are  cleansed  as 
for  any  operation,  and  the  skin  at  the  site  of  injection  is  sterilized  by 
painting  with  tincture  of  iodin. 

Technic. — In  order  to  prevent  any  undue  excitement,  the  injec- 
tion should  be  made  with  the  patient  in  such  a  position  that  he  cannot 

Fig.   165. — Sites  for  antitoxin  injection. 

see  what  is  going  on;  in  children  this  Is  especially  necessary.  Care 
must  be  taken  to  expel  any  air  from  the  syringe  by  elevating  its  point 
and  depressing  the  piston  a  little.  A  fold  of  the  skin  from  the  area 
previously  sterilized  is  then  raised  up  between  the  thumb  and  fore- 
finger of  the  left  hand,  and,  with  the  right  hand,  the  needle  is  quickly 
plunged  into  the  subcutaneous  tissue  (Fig.  166).  If  done  quickly 
with  a  sharp-pointed  needle,  preliminary  local  anesthesia  of  the  skin 
is  unnecessary.  The  serum  is  then  injected  very  slowly  and  the  swell- 
ing produced  is  not  massaged,  being  allowed  to  subside  as  the  serum 



is  absorbed.  After  withdrawal  of  the  needle  the  puncture  is  sealed 
with  collodion  and  cotton.  Following  the  injection  there  may  be  a 
slight  reaction  consisting  of  some  redness,  edema,  and  pain  at  the 
site  of  puncture,  but  these  usually  subside  in  a  short  time. 

Effects  of  Antitoxin. — In  favorable  cases  a  prompt  and  marked 
improvement  in  the  local  and  general  symptoms  follows  the  use  of 
antitoxin.  In  a  few  hours  the  pseudomembrane  begins  to  lose  its 
dirty  color  and  becomes  blanched  and  somewhat  swollen.  Within 
twelve  to  twenty-four  hours  the  membrane  loosens  at  the  edges  and 

Fig.   1 66. — Showing  the  method  of  injecting  diphtheria  antitoxin  in  the  subcuta- 
neous tissue  of  the  axilla. 

rolls  up,  becoming  detached  in  a  mass,  or  in  small  pieces.  This  seems 
to  take  place  more  rapidly  about  the  tonsils  than  elsewhere.  The 
usual  time  for  restoration  to  the  normal  condition  in  the  throat  is 
twenty-four  hours  to  three  or  four  days.  Sometimes  the  membrane, 
after  disappearing,  forms  again;  such  cases  should  promptly  receive 
more  antitoxin. 

In  nasal  diphtheria  similar  effects  are  observed,  each  irrigation 
bringing  away  small  or  large  pieces  of  detached  membrane.  The 
nasal  discharge  and  swelling  soon  diminish,  and  at  the  same  time  the 
mouth  breathing  ceases. 

In  laryngeal  diphtheria  antitoxin  prevents  the  extension  of  the 
membrane  into  the  trachea  and  bronchi  in  the  majority  of  cases,  and 
since  its  introduction  it  has  been  necessary  to  operate  upon  a  much 
smaller  proportion  of  cases  than  formerly. 



The  effects  upon  the  constitutional  symptoms  are  Ukewise  impres- 
sive. In  favorable  cases  the  general  condition  of  the  patient  improves 
noticeably  within  twelve  to  twenty-four  hours.  The  constitutional 
symptoms  of  toxemia  disappear,  the  color  and  general  appearance  are 
altered,  and  the  appetite  begins  to  improve.  The  temperature  may 
rise  I  or  2  degrees  in  the  first  four  or  five  hours  after  the  injection,  and 
the  pulse  may  be  accelerated  at  the  same  time,  but  this  is  followed  in 
favorable  cases  by  a  fall  of  the  fever  either  by  crisis  or  by  lysis  the 
temperature  becoming  practically  normal  in  two  or  three  days.  The 
persistence  of  fever  is  an  indication  for  a  second  dose  of  antitoxin. 

4  J 

YEAR                                                         I 

58  Se    So    91     92    93    94   95     9fe    97    98    99  00    0  1    02  03   04    05  06   07    08         1 












/     V 
















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— - 






CASE     FATALITY                                                                    1 

DEATH     RATE.                                                                          | 

Fig.   167. — Chart  prepared  by  the  New  York  Board  of  Health,  showing  the  reduc- 
tion in  the  mortaUty  from  diphtheria  since  the  introduction  of  antitoxin. 

The  reduction  in  the  mortahty  rate  since  the  introduction  of  anti- 
toxin is  well  shown  in  the  following  table  (Fig.  167)  prepared  by  the 
New  York  Department  of  Health,  the  small  reduction  shown  in  the 
first  three  years  of  its  use  being  explained  by  the  fact  that  sufficiently 
large  doses  of  antitoxin  were  not  used  at  first  and  that  the  serum  used 
later  was  more  efficient. 

Complications. — In  a  certain  percentage  of  cases  skin  eruptions 
develop  after  several  days.  These  may  be  erythematous,  scarlati- 
form,  morbiliform,  or  urticarial  in  character.  Urticaria  is  said  to 
follow  in  about  30  per  cent,  of  the  cases  and  usually  comes  on  from  the 
eighth  to  the  fourteenth  day.  It  frequently  develops  upon  the  but- 
tocks, abdomen,  and  chest  and  may  be  the  cause  of  great  discomfort 


and  annoyance  to  the  patient.     Infection  and  cellulitis  may  result 
from  the  injection  if  due  regard  to  asepsis  is  not  observed. 

Painful  conditions  in  the  large  joints,  as  the  hips,  knees,  wrists, 
and  shoulders,  occur  in  a  small  proportion  of  the  cases.  These  symp- 
toms, however,  are  not  due  to  the  antitoxin,  but  are  caused  by  the 
horse  serum,  and  depend  upon  the  susceptibility  of  the  patient  to  the 


Vaccination  is  the  inoculation  with  the  vaccine  or  virus  of  cowpox 
for  the  purpose  of  inducing  that  disease  in  man  and  thereby  affording 
partial  or  permanent  protection  against  smallpox. 

The  immunity  rendered  by  vaccination  is  not  claimed  to  be  invari- 
ably complete.  In  a  great  majority  of  cases,  though,  a  successful 
inoculation  grants  a  person  immunity  to  smallpox  for  a  number  of 
years,  though  the  effects  may  in  time  wear  off  and  the  individual  again 
become  susceptible.  The  mortality  in  such  cases,  however,  is  very 
low  compared  with  the  mortality  in  those  who  have  never  been  vac- 
cinated. According  to  Osier,  in  the  former  it  is  6  to  8  per  cent,  and  in 
the  unvaccinated  not  less  than  35  per  cent. 

The  nature  of  the  protection  thus  afforded  is  not  absolutely  under- 
stood, but  the  results  of  vaccination  are  unquestionable  and  admir- 
ably attest  its  efiEiciency.  Localities  in  which  vaccination  is  systemat- 
ically carried  out  develop  fewer  cases  and  present  the  lowest  death 
rate  from  smallpox.  In  Germany,  since  1874,  compulsory  vaccina- 
tion and  revaccination  have  been  enforced  and  since  then  there  have 
been  no  epidemics  of  smallpox  in  that  country.  On  the  other  hand, 
the  results  of  disregard  to  the  value  of  vaccination  are  well  illustrated 
by  the  mortality  rate  of  smallpox  in  European  countries  between 
1893  and  1897,  inclusive,  quoted  by  Schamberg  {New  York  Medical 
Journal,  Jan.  16,  1909)  from  the  Imperial  Board  of  Health  reports  of 
the  German  Empire.  He  says:  "We  are  startled  to  note  in  this  per- 
iod there  died  in  the  Russian  Empire,  including  Asiatic  Russia,  275,- 
502  persons  from  smallpox,  Spain  lost  over  23,000  lives,  Hungary  over 
12,000,  Austria  and  Italy  over  11,000.  In  Germany  the  number  of 
smallpox  deaths  during  this  period  was  only  287,  representing  one 
death  to  every  1,000,000  of  population  a  year." 

The  Virus. — The  virus  should  always  be  obtained  from  a  reliable 
source.  That  from  the  calf  is  to  be  used  by  preference.  Humanized 
lymph  should  never  be  employed  except  upon  imperative  occasions 
when  bovine  lymph  is  not  procurable. 



The  virus  is  obtained  under  rigid  aseptic  precautions  by  cujetting 
the  pustule  from  a  calf  and  making  an  emulsion  of  it  with  glycerin. 
This  is  then  collected  in  capillary  tubes  and  is  hermetically  sealed 
imtil  used.  The  lymph  should  not  be  distributed  until  it  has  been 
tested  for  tetanus  and  other  pathogenic  germs,  and  an  autopsy  has 
been  performed  upon  the  calf  to  make  certain  it  was  free  from  disease. 
The  lymph  may  also  be  obtained  spread  upon  ivory  or  celluloid  points, 
but  they  are  not  preferable  to  the  capiUary  tubes  as  there  is  danger  of 
the  virus  being  contaminated  by  handling. 

Time  for  Vaccination. — In  choosing  the  time  for  vaccination  the 
age  and  the  general  health  of  the  individual  should  be  taken  into 
consideration.  As  a  general  rule,  unless  contraindicated,  the  child 
should  be  three  to  sLx  months  old  before  vaccination.  The  operation 
should  be  avoided  if  possible  in  dentition;  and  children  who  are 
delicate  or  suffering  from  malnutrition,  syphihs,  or  skin  eruptions, 
should  not  be  vaccinated  until  in  good  condition.  The  best  season  is 
in  the  early  fall  or  spring  when  there  is  less  danger  of  epidemics  of 
contagious  diseases,  such  as  scarlet  fever,  measles,  diphtheria, 
whooping-cough,  etc.  Upon  exposure  to  smallpox,  whether  the  indi- 
vidual is  in  infancy  or  in  old  age.  he  should  always  be  immediately 

Instruments. — A  sharp-pointed  scalpel  or  a  lancet  is  as  useful  an 
instrument  as  can  be  found  for  performing  the  scarification.     Sharp 

5  ^ 

Fig.  168. — Xew  York  Department  of  Health  vaccination  outfit,  i,  Instru- 
ments in  case;  2,  rubber  tube  for  blowing  the  virus  out  of  the  tube;  3,  tube  con- 
taining virus;  4,  needle  for  scarification;  5,  stick  for  spreading  the  virus. 

needles  may  also  be  employed  and.  as  they  are  cheap,  the  same 
needle  need  not  be  used  for  more  than  one  case.  Special  scarificators 
are  made,  but  they  have  no  advantages  over  a  lancet  or  a  needle.  If 
the  vaccine  points  are  used,  no  scarificator  is  necessary. 

The  Xew  York  Department  of  Health  supplies  with  each  capillary 
tube  of  vaccine  virus,  a  needle,  a  flat  tooth  pick  for  spreading  the  virus. 



and  a  piece  of  small  rubber  tubing  which  fits  over  one  end  of  the  cap- 
illary tube  and  is  used  to  blow  the  vaccine  out  of  the  tube  (Fig.  i68). 
Site  of  Vaccination. — The  vaccination  is  performed  either  upon 
the  arm  or  leg.  As  a  rule,  the  arm  is  preferred  as  a  site,  especially  in 
children  who  are  running  about,  as  being  more  easily  kept  at  rest  and 
less  likely  to  be  injured.  Mothers  often  prefer  to  have  their  girls 
vaccinated  upon  the  leg  to  avoid  the  disfiguring  eiifect  of  the  scar. 
If  the  arm  is  chosen,  the  point  selected  is  at  about  the  insertion  of  the 
deltoid  muscle;  in  the  leg  a  spot  on  the  outer  aspect  at  the  junction 
of  the  middle  and  upper  third  is  selected. 

Fig.    169. — Vaccination.     First  step,  scarifying  the  arm. 

Asepsisi — The  operation  of  vaccination  should  be  regarded  as  an 
important  one  and,  as  most  of  its  dangers  are  due  to  infection,  the 
operator  should  see  that  all  aseptic  precautions  are  observed.  The 
instrument  employed  for  scarifying  the  skin  should  be  carefully  ster- 
ilized and  the  same  instrument  should  not  be  used  more  than  once 
without  resterilization.  The  hands  of  the  operator  are  prepared  as 
carefully  as  for  any  operation.  The  patient's  skin  is  washed  with 
soap  and  warm  water  followed  by  alcohol  and  ether  and  is  allowed  to 
dry.  The  use  of  strong  disinfectants  is  not  advised  as  the  chances  of  a 
successful  inoculation  may  be  lessened. 

Technic. — Vaccination  by  the  scarification  method  is  generally 
practised  in  this  country.  A  proper  spot  is  chosen  upon  the  arm  or 
leg.  and  an  area  1/8  to  1/4  inch  (3  to  6  mm.)  in  diameter  is  scarified 
by  making  a  number  of  scratches  at  right  angles  to  each  other  in 
the  skin  with  the  point  of  the  instrument  just  deep  enough  to  draw 



serum,  but  no  blood  (Fig.  169).     If  more  than  one  inoculation  is  to  be 
made,  as  is  frequently  done,  the  area  scarified  should  be  at  a  distance 

Fig.   170. — Vaccination.     Second  step,  blowing  the  virus  out  of  the  capillary  tube 
onto  a  small  piece  of  wood. 

Fig.   171. — Vaccination.     Third  step.     Rubbing  the  virus  into  the  scarified  area. 

of  at  least  i  inch  (2.5  cm.)  apart.  The  virus  is  then  deposited  upon 
the  scarified  area,  being  rubbed  in  with  some  sterile  instrument  for  a 
full  minute  and  allowed  to  dry  (Fig.  171).     The  site  of  vaccination  is 



finally  covered  with  a  piece  of  sterile  gauze  held  in  place  with  two 
small  strips  of  adhesive  plaster,  or,  if  desired,  a  wire  shield  (Fig.  172) 
may  be  used,  provided  it  is  applied  in  such  a  way  as  not  to  constrict 
the  arm  (Fig.  173).  After  the  vesicle  has  formed,  the  part  should  be 
gently  washed  with  sterile  water  once  a  day  and  dressed  with  fresh 
gauze  or  covered  with  a  shield  to  prevent  contact  with  the  clothing. 

Course  of  Vaccination. — Outside  of  a  little  irritation  and  redness 
at  the  site  of  inoculation  there  are  no  immediate  developments  and  the 
wound  heals.  On  the  third  day  a  papule  appears  surrounded  by  an 
area  of  slight  redness.  This  is  followed  in  twenty-four  hours  by  the 
formation  of  a  small  vesicle  which  by  the  seventh  or  eighth  day 
reaches  its  full  development.  It  is  usually  round,  1/4  to  1/2  inch 
(6  to  12  mm.)  in  diameter,  and  full  of  limpid  fluid.     The  center  of  the 

Fig.   172. — Vaccination  shield. 

Fig.   173. — Showing  the  shield  in  place. 

vesicle  is  depressed,  while  the  margins  are  elevated  and  shghtly  indur- 
ated. By  the  tenth  day  a  bright  red  areola  has  developed  covering  a 
space  of  from  i  to  2  inches  (2.5  to  5  cm.)  around  the  vesicle  and  the 
contents  of  the  vesicle  become  purulent.  In  a  day  or  two  more  the 
areola  commences  to  fade  and  the  vesicle  dries  up  forming  a  dark 
brown  crust.  Usually  about  the  twenty-first  day  this  crust  falls  off, 
leaving  a  bluish  pitted  scar  which  later  slowly  fades  to  white. 

Constitutional  symptoms  more  or  less  marked  accompany  the 
eruption.  Remittent  fever  of  from  101°  to  104°  begins  on  the  fourth 
day  and  may  persist  imtil  the  eighth  or  ninth  day.  when  it  drops 
gradually  to  normal.  In  children  irritabihty,  loss  of  appetite,  and 
restlessness  at  night  may  accompany  the  fever.     The  axillary  or 


inguinal  glands  become  swollen  and  sore,  depending  upon  whether 
the  arm  or  leg  is  the  seat  of  inoculation. 

Certain  irregular  types  of  vaccination  are  sometimes  met  with. 
In  rare  cases  a  generalized  vaccine  eruption  with  marked  fever  and 
other  severe  symptoms  may  occur.  Single  vesicles  may  also  be  pro- 
duced on  other  parts  of  the  body  distant  from  the  site  of  inoculation 
by  autoinoculation  from  scratching.  Sometimes  the  period  of  incu- 
bation is  prolonged  and  the  vesicle  formation  is  delayed. 

Complications. — Urticaria,  impetigo  contagiosa,  and  rashes  re- 
sembling those  of  scarlet  fever  or  measles  have  been  observed. 
Erysipelas  may  occur  at  any  time  before  the  sore  heals. 

Suppuration  and  abscess  of  the  axillary  or  inguinal  glands  some- 
times follow  vaccination.  In  anemic  and  unhealthy  subjects,  if 
infection  occurs,  cellulitis  and  deep  ulcers  may  form,  followed  by 
extensive  loss  of  tissue  and  large  scars. 

SyphiHs  is  no  longer  feared  under  modern  methods  of  vaccination ; 
the  same  is  true  of  tuberculosis,  and  it  has  been  shown  in  addition 
that  the  tubercle  bacillus  is  destroyed  in  glycerinated  lymph.  Tet- 
anus can  only  follow  carelessness  as  to  asepsis  and  neglect  of  pre- 
cautions in  preparing  the  lymph. 

Revaccination. — Immunity  furnished  by  vaccination  is  not  per- 
manent, and  in  all  persons  revaccination  should  be  performed  several 
years  after  the  first  vaccination.  The  New  York  Health  Department 
advises  that  revaccination  be  repeated  at  intervals  of  not  more  than 
three  years  if  permanent  immunity  is  to  be  acquired.  .  The  vaccina- 
tion should  be  as  thoroughly  carried  out  as  in  the  first  instance.  In 
cases  of  exposure  to  contagion  during  the  interval,  revaccination 
should  be  performed  at  once. 



For  the  purpose  of  relieving  the  pain  of  trifacial  neuralgia  various 
drugs  and  gases,  such  as  stovain,  cocain,  chloroform,  antipyrin,  osmic 
acid,  and  air,  have  been  injected  into  the  branches  of  the  fifth  nerve 
or  subcutaneously  into  the  painful  areas.  Schlosser  in  1900  was  the 
first  to  practise  direct  injection  of  the  different  branches  of  the 
fifth  nerve  with  80  per  cent,  alcohol  at  their  exit  from  the  skull  through 
the  basal  foramina.  Schlosser's  method  of  injection  was,  however, 
rather  difficult,  and  it  was  not  until  Levy  and  Baudouin  in  1906 
devised  a  comparatively  simple  technic  that  alcoholic  injections  were 
employed  to  any  great  extent.  While  injection  of  the  superficial 
branches  of  the  fifth  nerve  with  osmic  acid  and  the  deep  branches  with 
alcohol  have  both  given  brilliant  results,  the  use  of  osmic  acid  neces- 
sitates exposure  of  the  affected  nerve  or  nerves  and,  for  this  reason, 
it  has  been  largely  discarded  in  favor  of  alcohol  alone  or  in  combina- 
tion with  other  drugs. 

Alcohol  when  injected  into  a  nerve  causes  a  degeneration  of  its 
fibers.  Relief  from  pain  is  thus  obtained  usually  for  a  period  of  six 
months  to  two  years,  but  it  varies  considerably  depending  upon  the 
thoroughness  with  which  the  nerve  is  injected.  In  some  cases  one 
injection  has  given  an  apparent  cure,  bat,  as  a  rule,  the  injection 
has  to  be  repeated  several  times. 

All  three  branches  of  the  nerve  have  been  injected,^  but,  on 
account  of  the  difficulty  of  reaching  the  ophthalmic  branch  and  the 
proximity  of  the  optic  nerve,  and  the  third,  fourth,  and  sixth  nerves, 
deep  injection  of  this  branch  has  been  abandoned  by  the  majority  of 
operators . 

Anatomy. — The  fifth  nerve  closely  resembles  a  typical  spinal 
nerve,  being  a  mixed  nerve  with  its  sensory  and  motor  roots  arising 
separately  from  the  brain,  and  the  sensory  root  possessing  a  ganglion, 
the  Gasserian  ganglion.  The  latter  is  a  crescent-shaped  body,  com- 
posed of  nerve  fibers  and  nerve  cells,  lying  in  a  depression,  Meckel's 
cave,  on  the  apex  of  the  petrous  portion  of  the  temporal  bone.     From 

'  More  recently  injections  have  been  made  directly  into  the  Gasserian  ganglion. 




the  anterior  convex  border  of  the  ganglion  the  sensory  portion  emerges 
in  three  trunks:  the  ophthalmic,  the  superior  maxillary,  and  the 
inferior  maxillary.  The  superior  maxillary  division  is  joined  on  the 
distal  side  of  the  ganglion  by  the  motor  root. 

The  first  division  passes  from  the  skull  through  the  sphenoidal  fis- 
sure in  three  branches:  the  lachrymal,  the  frontal,  and  the  nasal.  It 
is  purely  a  sensor}-  nerve  supplying  the  upper  eyelid,  conjunctiva, 
eyeball,  lachrymal  gland,  forehead,  anterior  portion  of  the  scalp, 
frontal  sinus,  and  the  root  and  anterior  portion  of  the  nose. 

The  second  division  leaves  the  skull  through  the  foramen  rotundum, 
crosses  the  spheno-maxillary  fossa,  and,  after  entering  the  orbital 

Fig.   174. — Anatomy  of  the  trifacial  ner\^e.     (After  Campbell.) 

cavity  through  the  spheno-maxillary  fissure,  passes  to  the  face  by  way 
of  the  infraorbital  groove.  It  is  also  a  sensory  nerve,  supplying  the 
cheek,  anterior  portion  of  the  temporal  region,  the  lower  eyehd,  the 
ridge  of  the  nose,  upper  lip.  upper  teeth,  mucous  membrane  of  the 
nose,  nasopharynx,  antrum,  posterior  ethmoidal  cells,  soft  palate, 
tonsil,  and  roof  of  the  mouth. 

The  third  division  is  a  mixed  nerveformedby  the  third  trunk  of  the 
sensory  root  and  the  motor  root.  The  two  pass  from  the  cranium 
through  the  foramen  ovale  and  immediately  unite  to  form  a  single 
branch.  The  sensory  portion  of  the  nerve  supplies  the  skin  of  the 
side  of  the  head,  auricle  of  the  ear,  external  auditory  meatus,  lower 
portion  of  the  face,  lower  lip,  lower  teeth  and  gums,  mucous  mem- 



brane  of  the  mouth,  tongue,  and  mastoid  cells,  and  salivary  glands. 
The  motor  portion  supplies  the  muscles  of  mastication. 

Instruments. — There  will  be  required  a  special  needle  4  3/4  inches 
(12  cm.)  long  and  1/14  in.  (1.75  mm.)  in  diameter,  a  glass  syringe 
with  a  capacity  of  at  least  30  minims  (2  c.c),  a  scalpel,  a  fine  needle, 
2  1/2  inches  (5  cm.)  long  which  can  be  fitted  to  the  syringe  for  the 
purpose  of  infiltrating  the  skin  at  the  site  of  puncture  or  performing 
peripheral  injections  of  nerve  branches,  and  two  medicine  glasses, 
one  for  a  cocain  solution  and  the  other  for  the  alcohol  solution 
(Fig.  175)- 

Fig.  175. — Apparatus  for  injecting  the  branches  of  the  fifth  nerve,  i,  Two 
medicine  glasses;  2,  Luer  syringe;  3,  Levy  and  Baudouin  needle;  4,  small  hypo- 
dermic needle;  5,  ampoule  containing  anesthetic;  6,  scalpel. 

The  needle  should  have  rather  a  blunt  point  and  should  be  pro- 
vided with  a  stylet  which  extends  flush  with  the  point  of  the  needle 
when  pushed  home.  The  outside  of  the  needle  is  graduated  in  cen- 
timeters up  to  five.  The  proximal  end  of  the  needle  should  be  made 
to  accurately  fit  the  end  of  the  syringe  (Fig.  176). 

Fig.    176.— Enlarged  view  of  the  Levy  and  Baudouin  needle  and  stylet. 

Solution  Used. — The  solution  originally  used  was  a  mixture  of 
cocain,  morphin,  chloroform,  and  80  per  cent,  alcohol,  but  the  mor- 
phin  and  chloroform  are  generally  discarded  at  the  present  time.  The 
addition  of  chloroform  causes  considerable  inflammation  at  the 
site  of  injection  and  the  formation  of  scar  tissue.     Patrick  {Jour- 

nal of  the  Americaji  Medical  Association, 

Jan.  20,    1912'!   uses   the 

Cocain  muriat.,  gr.  ii  (0.13  gm.) 

Alcohol,  dr.  iiiss  (13  c.c.) 

Aq.  dest.,  q.s.  ad.,  oz.  ss  (15  c.c.) 

The  solution  should  be  freshly  prepared  for  each  injection. 



Quantity  Used. — For  a  deep  injection  3oTn.  (2  c.c.)  of  solu- 
tion are  generally  injected  into  each  branch.  Eight  minims  (0.5 
c.c.)  is  sufficient  for  a  peripheral  injection. 

Position  of  Patient. — The  injection  is  made  with  the  patient  sit- 
ting upright  in  a  chair  or  the  recumbent  position  may  be  employed 
with  the  patient's  head  resting  on  the  side. 

Asepsis. — The  instruments  are  sterilized  by  boiling,  the  operator's 
hands  cleansed  as  for  any  operation,  and  the  site  of  injection  painted 
with  tincture  of  iodin. 

Anesthesia. — General  anesthesia  is  to  be  avoided  if  possible,  as 
the  best  guide  to  a  successful  injection  is  the  spasm  of  pain  and  the 

Fig.   177. — Showing  the  method  of  injecting  the  supraorbital  branch  of  the  first 
division  of  the  fifth  nerve. 

anesthesia  that  results  over  the  area  of  distribution  of  the  nerve. 
Infiltration  of  the  skin  with  a  few  drops  of  0.2  per  cent,  cocain  solu- 
tion or  a  I  per  cent,  novocain  solution  at  the  point  through  which 
the  needle  enters  is  usually  sufficient. 

Technic. — The  site  of  injection  and  the  direction  in  which  the 
needle  islnserted  will  vary  according  to  the  branch  injected. 

First  Division. — Deep  injection  of  this  nerve  at  the  sphenoidal  fis- 
sure is  rarely  practised  on  account  of  its  dangers;  instead,  the  supra- 
orbital nerve  is  injected  at  the  supraorbital  notch  or  foramen.  The 
supraorbital  notch  is  located  by  palpation  or  by  the  sensations  of 
the  patient  when  the  nerve  is  compressed  between  the  finger  and  the 
skull.  The  skin  over  the  site  of  the  notch  is  anesthetized,  and  an 
attempt  Is  made  to  insert  the  fine  needle  into  the  foramen,  the  eye- 
ball being  protected  by  the  index  finger  of  the  operator's  left  hand 



(Fig.  177).  When  the  needle  strikes  the  nerve  a  sharp  shooting  pain 
will  be  felt  by  the  patient  extending  up  the  forehead.  If  possible, 
the  needle  should  be  inserted  for  a  distance  of  1/5  to  2/5  of  an  inch 
(5  to  10  mm.)  into  the  canal.  About  10  minims  (0.6  c.c.)  of  the 
alcohol  solution  is  then  injected.  A  successful  injection  will  result  in 
immediate  anesthesia  within  the  distribution  of  the  nerve. 

The  Second  Division  is  injected  at  the  foramen  rotundum.  The 
posterior  border  of  the  orbital  process  of  the  malar  bone  is  identified 
and  from  it  is  dropped  a  verticle  line  to  the  lower  border  of  the  zy- 
goma; 1/5  inch  (0.5  cm.)  behind  the  point  where  this  perpendicular 
line  crosses  the  zygoma  is  the  point  for  entrance  of  the  needle.     The 

Fig.   178. — -Needle  in  place  for  injecting  the  second  division  of  the  fifth  nerve. 

skin  at  this  point  is  infiltrated  with  cocain  and  is  nicked  with  a 
scalpel.  The  needle  is  inserted  with  the  stylet  withdrawn  until  it  is 
well  into  the  subcutaneous  tissues;  then  the  stylet  is  pushed  home  in 
order  to  furnish  a  blunt  point  and  avoid  any  injury  to  the  blood- 
vessels. The  direction  of  the  needle  should  be  at  first  horizontally 
inward  and  then  slightly  upward,  and  at  a  depth  of  2  inches  (5  cm.) 
the  needle  should  reach  the  nerve  at  the  foramen  rotundum.  If, 
after  passing  through  the  subcutaneous  tissue,  the  needle  strike  the 
coronoid  process  of  the  lower  jaw,  it  will  have  to  be  re-inserted  at  a 
point  shghtly  more  forward.  This  will  necessitate  changing  the 
angle  of  the  needle  to  correspond  with  the  new  site  of  entrance.  Care 
must  be  observed  against  inserting  the  needle  so  far  forward  that  the 
orbit  will  be  entered  or  so  deep  that  the  sixth  nerve  is  reached.  With 
the  needle  introduced  the  correct  distance,  the  stylet  is  withdrawn 



and  the  alcohol  solution  is  slowly  injected  and,  if  the  needle  is  prop- 
erly placed,  a  sharp  pain  will  be  felt  by  the  patient  in  the  area  of 
distribution  of  the  nerve.  If  the  nerve  is  not  reached,  the  needle 
should  be  withdrawn  a  little  and  its  direction  shghtly  changed.  At 
the  completion  of  the  injection,  the  needle  is  removed  and  the  point 
of  puncture  is  sealed  with  collodion  and  cotton.  The  patient  should 
be  kept  in  a  recumbent  position  for  10  to  15  minutes. 

If  it  is  found  impossible  to  reach  the  nerve  at  its  exit  from  the 
skull,  its  infraorbital  branch  may  be  injected  at  the  infraorbital 
foramen,  using  a  long  fine  needle  for  this  purpose.  About  10  to  15 
minims  (0.6  to  i  c.c.)  of  the  solution  are  injected. 

The  Third  Division  is  injected  at  the  foramen  ovale.  The  descend- 
ing root  of  the  zygoma  is  identified,  and  at  a  point  I  inch  (2.5  cm.) 
in  front  of  it  just  below  the  zygoma,  the  needle  enters  the  skin.  The 
skin  at  this  point  is  anesthetized  and  is  nicked  with  a  scalpel,  and  the 
needle  with  the  stylet  withdrawn  is  pushed  through  the  subcutaneous 

Fig.   179.-— Needle  in  place  for  injecting  the  third  division   of  the  fifth  nerve. 

tissues  in  a  direction  slightly  upward  and  backward.  The  stylet  is 
then  pushed  home,  and  needle  is  carried  in  through  the  deeper  tis- 
sues, still  slightly  upward  and  backward,  until  it  reaches  a  depth  of 
1 1/2  inches  (4  cm.);  it  should  then  be  at  the  foramen  ovale.  When  the 
needle  strikes  the  nerve,  the  patient,  as  a  rule,  will  be  conscious  of  a 
sharp  pain  in  the  tongue  or  lower  jaw.  The  stylet  is  then  removed, 
the  syringe,  loaded  with  the  alcohol  solution,  is  fitted  to  the  needle, 
and  the  injection  is  made.  At  the  completion  of  the  operation,  the 
needle  is  withdrawn  and  the  skin  puncture  is  sealed  with  collodion 
and  cotton. 



Following  a  deep  injection,  there  is  considerable  swelling  of  the 
face,  which  the  patient  should  be  warned  beforehand  to  expect. 
Sometimes  a  hematoma  may  result  from  puncture  of  some  vessel 
during  the  insertion  of  the  needle.  To  avoid  this,  Patrick  advises 
that  the  needle  always  be  inspected  for  oozing  and,  if  present, 
that  the  needle  and  stylet  be  left  in  place  until  it  stops. 


The  injection  of  alcohol  and  other  drugs  which  have  a  destructive 
action  upon  nerves  and  which  have  been  effectively  employed  in 
neuralgia  of  the  fifth  nerve  should  be  avoided  in  sciatica,  as  the  sciatic 
is  a  mLxed  nerve  and  the  use  of  such  drugs  has  produced  grave  motor 
changes- in  the  nerve.     The  injection  of  physiological  salt  solution, 

Fig.  i8o. — Apparatus  for  injecting  the  sciatic  nerve.  I,  Medicine  glass;  2, 
glass  graduate;  3,  large  glass  syringe  and  blunt  needle  for  injecting  the  nerve;  4, 
ampoule  of  cocain;  5,  small  syringe  and  needle  for  the  preliminary  infiltration  of 
the  site  of  puncture;  6,  scalpel. 

however,  has  given  good  results  in  relieving  the  pain  of  sciatica  with- 
out causing  any  harmful  results.  The  injection  is  made  into  the 
nerve-sheath  with  the  idea  of  separating  the  adhesions  that  have 
formed  around  the  inflamed  nerve,  and,  if  it  is  used  in  the  proper 
cases,  in  the  great  majority  of  instances  it  gives  rehef.  Frequently 
more  than  one,  and  in  the  severe  cases,  a  number  of  injections  are 
required  to  produce  a  cure. 

Apparatus. — There  will  be  required  a  needle  43/4  inches  (12 
cm.)  long  and  1/16  inch  (1.5  mm.)  in  diameter,  a  glass  syringe  with 
a  capacity  of  3  to  4  ounces  (90  to  120  c.c),  a  piece  of  rubber  tubing  to 
connect  the  syringe  and  needle,  a  scalpel,  a  cocain  syringe,  a  small 
medicine  glass  for  the  cocain  solution,  and  a  glass  graduate  for  the 
salt  solution  (Fig.  180). 



The  needle  is  of  a  type  similar  to  that  used  for  trifacial  injections 
(see  Fig.  176).  It  should  be  graduated  in  centimeters  from  i  to  10, 
and  the  point  should  be  rather  blunt. 

Solution  Used. — ^Normal  salt  solution  (salt  i  dram  (4  gm.)  to  a 
pint  (500  c.c.)  of  boiled  water)  with  or  without  the  addition  of  a  local 
anesthetic  is  used. 

Temperature  of  the  Solution. — The  solution  is  injected  either  at 
about  the  temperature  of  the  body  or  at  32°  F.  (0°  C). 

Quantity. — Two  to  4  ounces  (60  to  120  c.c.)  of  the  warm  solution 
and  2  1/2  to  5  drams  (10  to  20  c.c.)  of  the  cold  solution  may  be 

Intervals  between  Injections. — When  it  is  necessary  to  repeat 
the  injections,  they  may  be  given  at  intervals  of  24  to  72  hours. 

Site  of  Injection. — Several  points  for  reaching  the  nerve  are 
advised.     That  used  by  D'Orsay  Hoecht  and  one  that  gives  access  to 

Fig.   181. — Showing  the  method   of  locating  the  point  for  injecting  the  sciatic 

nerve.     (After  Hoecht.) 

the  nerve  high  up  is  as  follows:  A  line  is  drawn  from  the  sacrococ- 
cygeal joint  to  the  postero-external  border  of  the  great  trochanter, 
and  one  finger's  breadth  external  to  the  junction  of  the  inner  one-third 
and  outer  two-third  of  this  line  is  the  point  for  inserting  the  needle 
(Fig.  181). 

The  nerve  may  also  be  reached  by  inserting  the  needle  at  a  point 
where  a  horizontal  line  through  the  tip  of  the  great  trochanter  cuts  a 
verticle  line  through  the  outer  margin  of  the  tuberosity  of  the  ischium. 

Position  of  the  Patient.^ — The  patient  lies  upon  the  abdomen  with 
the  legs  extended  and  with  a  pillow  beneath  the  groins. 


Asepsis. — The  instruments  are  boiled,  the  hands  of  the  operator 
are  sterilized  as  carefully  as  for  any  operation,  and  the  field  of  opera- 
tion is  painted  with  tincture  of  iodin. 

Anesthesia. — The  point  on  the  skin  through  which  the  needle  is 
inserted  is  anesthetized  by  infiltration  with  a  few  drops  of  a  0.2 
per  cent,  solution  of  cocain  or  a  i  per  cent,  solution  of  novocain. 

Technic. — The  syringe  is  filled  with  the  salt  solution  of  the  proper 
temperature  and  is  placed  ready  for  use  near  at  hand.  A  small  nick 
is  made  in  the  skin  at  the  point  chosen  for  the  puncture,  and  the 
needle,  armed  with  the  stylet,  is  inserted  perpendicularly  to  the  body 
through  the  tissues  until  it  hits  the  nerve.  If  the  needle  strikes  bone, 
it  is  then  withdrawn  1/25  inch  (i  mm.)  and  should  be  in  close  prox- 
imity to  the  nerve.  The  moment  the  nerve  is  reached  the  patient 
experiences  a  sharp  lancinating  pain  low  down  the  back  of  the  leg  or 
in  the  heel,  frequently  accompanied  by  a  jerking  motion  of  the  leg. 
The  stylet  is  then  removed,  the  syringe  is  attached  to  the  needle,  and 
the  desired  amount  of  solution  is  slowly  and  steadily  injected.  At 
the  end  of  the  injection,  the  needle  is  removed,  and  the  site  of  skin 
puncture  is  sealed  with  collodion  and  cotton. 

Following  the  injection,  the  patient  should  be  instructed  to  keep 
quiet  for  several  days.  For  the  first  few  days  there  may  be  some  sore- 
ness, and  not  infrequently  there  is  a  slight  rise  of  temperature  for  the 
first  24  to  48  hours. 






While  the  value  of  artificially  producing  hyperemia  with  the 
definite  purpose  of  increasing  the  inflammatory  reaction  has  only 
recently  been  recognized,  it  is  interesting  to  note  that  as  early  as  the 
sixteenth  century  Ambroise  Pare  employed  artificial  congestion  in 
delayed  union  of  fracture  due  to  insufficient  callus  formation.  Others 
later  and  independently  have  called  attention  to  the  value  of  hypere- 
mia in  similar  conditions.  To  Bier,  however,  belongs  the  credit  of 
placing  treatment  by  hyperemia  upon  a  logical  and  scientific  basis, 
and  of  demonstrating  its  great  practical  value. 

There  are  two  distinct  forms  of  hyperemia,  namely,  active  and 
passive.  The  former,  obtained  by  means  of  dry  hot  air,  produces  a 
more  active  flow  of  arterial  blood  through  the  parts,  and  is  especially 
useful  for  the  absorption  of  the  products  of  chronic,  nontubercular 
inflammations.  The  passive,  venous,  or  obstructive  form  of  hypere- 
mia, as  it  is  designated,  has  for  its  object  the  increase  of  the  amount 
of  venous  blood  in  the  part,  and  may  be  produced  by  means  of  elastic 
compression  of  the  venous  circulation,  or  by  suction  cups.  This 
form  gives  the  best  results  in  pyogenic  infections,  whether  acute  or 


Bier  was  first  led  to  employ  passive  hyperemia  through  study  of 
the  observations  of  Farre  and  Travers  who,  as  far  back  as  1815, 
called  attention  to  the  frequency  of  phthisis  in  persons  whose  lungs 
were  rendered  anemic  because  of  stenosis  of  the  pulmonary  orifice, 
and  by  the  reverse  of  this,  namely,  the  rarity  of  pulmonary  tubercu- 
losis in  individuals  suffering  from  cardiac  conditions  tending  to  pro- 
duce congestion  or  hyperemia  of  the  lungs,  as  later  pointed  out  by 
Rokitansky.  Impressed  by  these  observations,  Bier  conceived  the 
idea  of  artificially  producing  a  hyperemia  for  the  cure  of  tubercular 
affections  in  other  parts  of  the  body.     Encouraged  by  the  results 



-  obtained  in  the  treatment  of  tubercular  affections,  he  soon  extended 
the  use  of  hyperemia  to  the  treatment  of  acute  inflammatory  surgical 
conditions,  with  most  remarkable  results.  In  this  he  was  materially 
aided  by  his  associate,  Klapp,  who  broadened  the  scope  of  the  method 
by  devising  variously  shaped  glass  cups  and  vacuum  apparatus  for 
producing  a  hyperemia  of  regions  of  the  body  not  amenable  to  the 
constricting  band,  though  it  is  true  Bier  had  himself  employed  this 
method  previously  and  had  abandoned  it. 

Treatment  by  hyperemia  is  based  on  the  theory  that  inflamma- 
tion represents  nature's  efforts  for  protection  of  the  body  against 
bacterial  invasion  and  in  the  restoration  of  a  part  to  a  healthy  condi- 
tion. Bier's  teachings  in  regard  to  inflammation  take  exactly  the 
opposite  view  from  what  has  hitherto  been  held  and  taught.  For- 
merly it  was  the  aim  of  treatment  to  combat  in  every  way  possible 
the  phenomena  accompanying  an  inflammation.  In  the  presence  of 
pain,  heat,  redness,  and  swelling,  cold  applications,  elevation  of  the 
part,  rest,  and  immobilization  were  advocated  for  the  rehef  of  these 
symptoms.  According  to  Bier,  however,  the  redness,  heat,  and 
swelling  of  an  inflammation  are  but  the  outward  signs  of  the  effort  on 
the  part  of  nature  to  overcome  noxious  influences  and  produce  a  cure; 
and  these  are  to  be  encouraged  as  beneficial  instead  of  combated.  An 
attempt  was  accordingly  made  to  artificially  reproduce  the  most 
evident  of  these  phenomena,  namely,  congestion  or  hyperemia,  and 
thereby  increase  the  natural  resistance  of  the  tissues. 

Difficult  as  it  may  be  to  give  up  our  old  ideas  and  accept  a 
method  of  treatment  so  radically  at  variance  with  former  teachings, 
the  results  obtained  under  hyperemia,  properly  carried  out,  are  in 
certain  cases  so  remarkable  and  so  far  in  advance  of  any  other 
methods  as  to  furnish  ample  evidence  of  its  superior  value  and  to 
prove  conclusively  the  correctness  of  the  theories  upon  which  Bier's 
treatment  rests. 

Effects  of  Hyperemia. — The  beneficial  effects  of  hyperemia  are 
most  striking — the  more  marked,  the  earlier  the  treatment  is  begun. 

Diminution  of  Pain. — The  prompt  relief  of  pain  is  one  of  the  most 
remarkable  features  of  the  treatment.  Accepting  the  theory  that 
»  pain  from  an  inflammation  is  due  to  irritation  of  the  cells  and  end 
organs  by  toxins,  as  well  as  to  the  high  specific  gravity  of  the  inflam- 
matory exudate,  its  relief  under  the  influence  of  hyperemia,  which 
both  destroys  and  dilutes  toxins  and  also  dilutes  the  exudates,  may 
be  readily  understood.  If  pain  be  not  relieved,  or  at  least  mitigated, 
or  if  discomfort  results  from  the  treatment,  the  operator's  technic  is 


probably  at  fault.  The  patient  should  always  be  impressed  with  the 
necessity  of  reporting  any  discomfort  in  the  part  subjected  to  the 
hyperemia,  and  his  sensations  should  be  an  important  guide  for  the 

Through  the  prompt  decrease  of  pain  and  sensitiveness,  reflex 
contracture  of  muscles  is  avoided  and  earlier  motion  in  a  part  is  pos- 
sible. This  is  especially  important  in  infections  involving  tendon 
sheaths  and  joints,  as  with  early  motion  much  better  functional  re- 
sults are  possible.  Even  in  an  extremely  sensitive  joint,  it  is  remark- 
able how  quickly  slight  motion  may  be  painlessly  practised  under 

Bactericidal  Action. — It  has  been  shown  by  experiments  upon 
animals  as  well  as  by  clinical  evidence  that  through  hyperemia  cer- 
tain forces  are  brought  to  bear  which  either  directly  or  indirectly 
antagonize  bacterial  growth  and  either  destroy  or  dilute  the  toxins. 
Beginning  infection,  such  as  a  furuncle  or  a  carbuncle,  in  which  red- 
ness, tenderness,  swelling,  and  slight  infiltration  are  the  only  signs 
present,  can  thus  often  be  made  to  subside  without  suppuration, 
while,  if  suppuration  has  already  developed,  the  infectious  process 
may  be  prevented  from  extending  to  the  deeper  tissues  and  the  cKn- 
ical  course  be  greatly  shortened.  Accidental  soiled  wounds,  which 
from  experience  we  have  every  reason  to  beHeve  will  become  infected, 
under  the  influence  of  hyperemia  can  often  be  made  to  heal  without 
infection,  and  not  infrequently  by  primary  union,  and  there  is  no 
better  means  than  the  increased  secretion  induced  by  the  hyperemia 
for  thoroughly  flushing  out  and  rapidly  cleansing  these  dirty  wounds. 

There  is  considerable  difference  of  opinion  as  to  the  agent  under- 
lying this  bactericidal  action,  and  several  theories  have  been  advanced 
in  explanation.  Some  believe  that  it  is  due  to  an  increase  in  the 
phagocytes;  some  consider  the  carbonic  acid  of  the  venous  blood  to  be 
the  agent;  others  offer  Wright's  theory  as  to  increase  of  the  opsonic 
index  as  the  beneficent  factor;  and  still  others  claim  that  the  in- 
creased transudate  induced  by  the  hyperemia  mechanically  flushes 
out  the  affected  part  and  thereby  dilutes  the  toxins  and  removes  dead 
bacteria.  It  is  difficult  to  say  which  is  the  exact  cause.  Bier  him- 
self, I  believe,  inclines  to  the  phagocytosis  theory.  Personally,  the 
writer  feels  that  the  mechanical  flushing  of  the  part  by  the  increased 
transudate  is  quite  an  important  factor,  especially  in  the  presence  of 
open  wounds  or  sinuses. 

Limitation  of  the  Pathological  Process. — Under  hyperemia,  necrosis 
of  even  badly  damaged  parts  is  often  prevented  by  the  superabundant 

2o6  bier's  hyperemic  treatment 

nourishment  of  the  tissues,  or,  when  the  infection  has  advanced  to  the 
destruction  of  tissues,  the  disease  process  is  more  promptly  localized, 
and  a  line  of  demarcation  between  the  healthy  and  diseased  tissues  is 
earlier  in  evidence.  Sloughs  and  sequestra  are  thus  early  separated 
and  cast  off,  while  in  tubercular  aft'ections  connective  tissue  replaces 
the  tubercular,  and  the  disease  gradually  dies  out. 

Solvent  and  Absorbent  Action. — Both  the  active  and  the  passive 
forms  of  hyperemia  act  as  solvents,  while  the  active,  in  addition,  has 
a  very  marked  absorbent  action.  The  products  of  inflammation,  as 
infiltrations,  exudates,  and  plastic  changes,  are  dissolved,  so  to  speak, 
and  their  absorption  is  thus  favored.  Careful  application  of  hyper- 
emia thus  makes  unnecessary  many  of  the  operations  of  resection,  etc. 
This  is  well  illustrated  in  the  excellent  functional  results,  with  free- 
dom from  ankylosis  and  deformity,  obtained  in  tubercular  and  other 
joint  affections. 

Indications. — Passive  hyperemia  has  been  recommended  for  all 
kinds  of  acute  inflammatory  processes  and  many  of  the  chronic  ones, 
and  the  literature  of  the  past  few  years  teems  with  numerous  favor- 
able reports  of  its  use,  not  only  in  purely  surgical  affections,  but  in 
the  specialties  and  in  medicine  as  well. 

The  surgical  conditions  in  which  it  has  been  found  to  be  especially 
beneficial  may  be  summarized  as  follows:  Acute  infections  and  in- 
flammations, such  as  furuncles,  carbuncles,  felons,  infected  wounds, 
infection  of  tendon  sheaths,  lymphangitis,  lymphadenitis,  mastitis, 
gonorrheal  arthritis,  and  other  forms  of  acute  infections  of  joints, 
acute  bone  infections,  burns;  as  a  prophylactic  measure  in  soiled  or 
dirty  wounds,  compound  fractures;  in  chronic  afi'ections,  such  as 
tuberculosis  of  bones,  joints,  glands,  tendon  sheaths,  testicles;  delayed 
union  of  fractures;  fistulae;  old  discharging  sinuses;  and  infected  leg 
ulcers  uncompHcated  by  varicose  veins.  Its  use  is,  however,  contra- 
indicated  in  lesions  compHcated  by  thrombosis  of  veins.  In  ery- 
sipelas its  value  is  doubtful;  in  fact,  erysipelas  has  been  known  to 
develop  under  prolonged  h}^eremia  in  tubercular  lesions  which  were 
complicated  by  open  sinuses.  In  diabetes,  likewise,  the  results  have 
not  always  been  good. 

Passive  hyperemia  has  also  been  employed  with  success  in  medi- 
cine for  such  conditions  as  acute  rheumatism,  gout,  and  pulmonary 
tuberculosis.  For  the  latter  condition  Kuhn  has  devised  a  mask  of 
thin  celluloid  which  by  means  of  an  adjustable  valve  cuts  off  some  of 
the  air  entering  the  alveoli  and  thus  induces  a  suction  hyperemia. 
In  a  host  of  other  affections  falling  within  the  domain  of  rhinology, 


otology,  gynecology,  obstetrics,  and  dermatology,  passive  hyperemia 
has  been  recommended  and  appHed  with  varying  degrees  of  success. 

General  Principles  Underlying  Hyperemic  Treatment. — As  em- 
phasized by  the  author  of  this  method  of  treatment,  and  others,  it  is 
not  a  panacea  or  cure  for  all  troubles.  One  should  recognize  that  it 
has  its  limitations.  In  some  of  the  milder  forms  of  infection,  com- 
plete cure  may  often  be  effected  by  hyperemia  alone;  in  other  cases, 
of  the  more  severe  infections,  it  forms  only  a  part  of  the  treatment, 
and  operative  interference  should  never  be  delayed  when  indicated. 
Pus  ?nust  always  be  promptly  evacuated,  and  cold  abscesses  likewise 
are  to  be  opened.  This  is  accomplished  by  small  incisions  or  punc- 
tures, the  old-time  extensive  incisions,  which  often  result  in  unsightly 
scars  and  even  deformities,  being  unnecessary  under  this  form  of 
treatment.  The  hemorrhage  incident  to  such  incisions  should  be 
controlled  by  packing  the  wound  for  two  to  three  hours  before  the 
hyperemia  is  induced.  In  an  infection  of  the  tendon  sheaths,  the 
anatomy  of  the  parts  should  be  carefully  kept  in  mind  and  the  inci- 
sions made  accordingly.  Small  multiple  incisions  are  employed  and 
should  be  so  placed  as  to  avoid  cutting  the  transverse  palmar  liga- 
ments opposite  the  finger  joints.  In  the  case  of  infection  of  a  large 
joint,  the  pus  is  aspirated  and  the  joint  cavity  is  irrigated  through  a 
large  trocar;  in  other  localities,  ordinary  surgical  principles  should  be 
the  guide  as  to  the  incision.  The  curettage  of  abscess  cavities  is 
avoided,  while  drains  and  tampons  are  discarded,  as  the  secretions 
that  are  poured  out  under  the  artificial  hyperemia  serve  to  keep  the 
wound  open.  Certain  cases  of  very  rapidly  extending  infection,  with 
acute  onset,  however,  require  early  incision  in  conjunction  with  the 
hyperemia,  even  before  softening  has  occurred.  If  incisions  are  not 
made,  the  hyperemia  may  do  harm  and  the  local  inflammation  be- 
come worse,  for  the  transudate  which  is  induced  by  the  hyperemia, 
added  to  the  exudate  already  present,  has  no  outlet  and  may  drive 
the  bacteria  and  their  toxins  into  healthy  tissue  and  favor  the  exten- 
sion of  the  infection. 

In  inflammations  involving  joints  or  tendon  sheaths,  mild  active 
and  passive  motion  are  carried  out  from  the  first  day,  in  order  to  obtain 
the  best  functional  results,  provided  this  can  be  done  without  pro- 
ducing pain.  Slight  motion  is  harmless  so  long  as  it  is  painless.  For 
this  reason,  no  immobilizing  dressing  need  be  applied  during  the 
treatment,  open  wounds  being  merely  covered  with  moist  antiseptic 

In  acute  infections,  the  results  are  often  prompt  and  most  strik- 

2o8  bier's  hyperemic  treatment 

ing.  In  favorable  cases,  the  temperature  declines,  pain  is  relieved, 
extension  to  deeper  tissues  is  prevented,  and  the  process  rapidly  sub- 
sides or  at  least  the  clinical  course  is  much  shortened.  Swelling  and 
redness  are  temporarily  increased,  and  are  to  be  expected  as  part  of 
the  treatment.  The  discharge  from  open  wounds  is  at  first  most 
abundant,  but  this  likewise  rapidly  subsides,  and  with  it  the  edema 
and  redness. 

In  chronic  lesions  of  a  tubercular  nature,  the  treatment  must  be 
carried  out  for  months.  In  the  case  of  joints,  the  pain  and  swelling 
slowly  diminish,  the  contour  of  the  joint  again  becomes  distinguish- 
able, and  mobility  gradually  increases;  secretions  from  sinuses  be- 
come serous  instead  of  purulent,  the  sinus  taken  on  a  healthy  appear- 
ance and  finally  closes.  In  tubercular  affections,  likewise,  slight 
motion  of  the  affected  limb  is  allowed,  provided  it  produces  no  pain. 
Fixation  of  the  joint,  in  cases  of  tuberculosis  of  the  wrist,  elbow,  or 
shoulder  can  thus  usually  be  dispensed  with — a  sling  at  most  is  used — 
but  in  knee  or  foot  tuberculosis  a  suitable  apparatus  should  be  worn, 
or  the  part  so  immobilized  by  a  movable  splint  when  the  patient  is 
moving  about  that  pressure  is  removed  from  the  diseased  articular 
surfaces.  In  the  presence  of  contractures  of  the  joints,  suitable 
extension  is  applied  and  used  in  conjunction  with  the  hyperemic 

Bier  gives  as  contraindications  to  the  use  of  hyperemia  in  tuber- 
culosis of  joints  the  following: 

1.  Commencing  amyloid  disease  and  advanced  pulmonary 

2.  Large  abscesses,  filling  up  the  whole  joint  cavity  and  demand- 
ing operation. 

3.  Faulty  position  of  the  joint,  such  that  cure  would  give  a  joint 
less  useful  than  could  be  obtained  by  resection.  In  such  conditions 
he  advises  operative  interference. 

Successful  hyperemic  treatment  necessitates  correct  technic,  and 
many  of  the  poor  results  at  first  obtained  by  those  unfamiliar  with 
this  method  may  be  ascribed  to  errors  in  this  direction.  It  certainly 
requires  time  and  close  attention,  as  well  as  considerable  experience 
on  the  part  of  the  attendant,  to  obtain  good  results;  but,  if  the  treat- 
ment be  properly  carried  out  with  perseverance,  one  will  be  amply 
repaid.  At  first  the  patient  must  be  carefully  watched  as,  with  the 
use  of  the  elastic  band,  for  instance,  it  may  be  necessary  to  remove  or 
reapply  the  constriction  several  times  in  the  course  of  a  single  treat- 
ment in  order  to  maintain  the  proper  degree  of  hyperemia.     Intelli- 



gent  patients  may  later  be  instructed  in  carrying  out  the  treatment 
with  either  the  bandage  or  the  cup,  and  in  time  they  themselves  can 
apply  the  treatment  at  home,  but  they  should  always  remain  under 
the  supervision  of  the  surgeon. 

Methods  of  Producing  Passive  Hyperemia. — As  already  indicated 
the  passive  form  of  hyperemia  may  be  obtained  by  means  of  soft 
rubber  bandages  or  by  special  suction  apparatus.  The  principle  in 
each  is  the  same,  but  the  technic  requires  special  description. 

Passive  Hyperemia  by  Means  of  Constricting  Bands. — This 
is  the  oldest  method  of  producing  an  obstructive  hyperemia.  It  is 
especially  applicable  to  affections  involving  the  extremities,  head, 
and  neck.  The  hip-joint  is  the  only  one  in  either  of  the  extremities 
to  which  the  method  cannot  be  satisfactorily  applied.  There  is  no 
doubt  that  the  proper  application  of  the  band  requires  more  skill 
than  does  cupping.     Exact  technic  is  necessary,  and  great  caution 

Fig.   182. — Esmarch  elastic  bandage  for  obstructive  hyperemia. 

must  be  observed  not  to  exceed  the  proper  grade  of  hyperemia,  and 
in  tubercular  cases  not  to  lower  the  vitality  of  the  tissues  by  too  pro- 
longed obstruction.  Only  a  mild  hyperemia  is  necessary  to  produce 
results;  otherwise,  distinct  harm  is  done.  For  this  reason,  the  band- 
age should  be  applied  by  the  surgeon  himself  until  an  intelligent 
and  competent  person  of  the  household  can  be  instructed  in  its 
proper  application. 

Apparatus. — For  most  cases,  a  soft,  thin  elastic  bandage,  such  as 
Esmarch's  or  Martin's,  about  2  1/2  inches  (6  cm.)  in  breadth,  is 
employed  (Fig.  182). 

For  the  shoulder-joint  and  testicles,  rubber  tubing  is  used  in  place 
of  a  bandage.  That  used  about  the  shoulder  should  be  of  fairly 
stout  rubber,  and  about  a  foot  long  (30  cm.) ;  while  for  the  scrotum, 
a  catheter  or  a  piece  of  drainage-tube  of  small  size  answers. 

To  produce  hyperemia  of  the  head  and  neck,  a  rubber  bandage 

measuring  about  i  1/4  inches  (3  cm.)  in  width  may  be  used,  or  a 

special  neck-band  made  for  the  purpose  may  be  obtained.     A  garter 

elastic,  about  i  inch  (2.5  cm.)  in  width  and  provided  with  hooks  and 



eyes  so  that  it  may  be  adjusted  to  any  size,  as  shown  by  the  ac- 
companying illustration  (Fig.  183),  answers  the  purpose  admirably. 
Site  of  Application. — The  constriction  should  always  be  applied 
over  healthy  tissue  and  well  above  the  area  of  inflammation.  In 
involvement  of  the  hand,  for  instance,  the  bandage  is  applied  above 
the  elbow,  and  above  the  knee  if  the  foot  be  the  seat  of  trouble.  To 
avoid  undue  compression  continually  at  the  same  spot,  it  is  well  to 
change  the  location  of  the  bandage  at  each  application,  moving  it  a 
little  either  up  or  down  the  limb. 

Fig.   T83.— Elastic    garter    for   producing  obstructive  hyperemia  of   the    neck. 
(After  Meyer-Schmieden.) 

Duration  of  Application. — In  the  treatment  of  acute  processes, 
the  best  results  are  obtained  from  prolonged  stasis,  namely,  from 
twenty  to  twenty- two  hours  a  day.  The  bandage  is  accordingly 
applied  for  ten  or  eleven  hours,  then  discarded  for  two  or  one  hours, 
and  reapplied  for  another  ten  to  eleven  hours.  The  bandage  is 
applied  daily  and,  as  the  condition  improves,  the  duration  of  the 
daily  constriction  may  be  diminished  until  it  is  only  of  from  one  to 
two  hours. 

For  tubercular  affections  shorter  applications  are  used,  the  band- 
age being  applied  once  or  twice  a  day  from  one  to  four  hours  at  a 
time.  In  his  early  work  on  tubercular  affections.  Bier  first  employed 
short  periods  of  hyperemia,  and  then  prolonged  and  almost  con- 
tinuous hyperemia,  but  he  experienced  many  failures  and  bad  results 
with  the  latter.  He  found  that  prolonged  stasis  in  this  class  of 
cases  was  apt  to  devitalize  the  parts  and  lead  to  the  rapid  formation 
of  cold  abscess,  as  well  as  to  the  development  of  septic  abscess, 
lymphangitis,  adenitis,  erysipelas,  etc.,  so  that  he  returned  to  the 
short  applications  of  from  one  to  four  hours  a  day.  In  cases  of 
acute  hot  abscess  formation,  however,  due  to  a  mixed  infection  of 
open  sinuses,  the  application  may  be  extended  to  the  longer  periods 
■ — twice,  ten  or  eleven  hours — until  the  acute  process  has  subsided. 

Technic. — To  apply  the  bandage,  its  initial  extremity  is  first  wet 
sufljciently  to  make  it  adhere  to  the  skin  and  prevent  it  from  slipping. 



The  bandge  is  wound  around  the  hmb  with  moderate  tension  six  or 
eight  times  well  above  the  seat  of  disease,  each  layer  overlapping  the 
preceding  by  about  1/2  inch  (i  cm.).  The  bandage  is  then  made 
secure  by  adhesive  plaster  or  tapes  previously  sewed  to  the  terminal 
end  (Fig.  184). 

The  degree  of  h}'peremia  is  of  the  utmost  importance.  The 
object  is  to  moderately  constrict  the  veins  of  a  part,  without  in 
any  way  interfering  with  the  arterial  supply,  thereby  partly  checking 
the  reflux  of  blood  and  increasing  the  quantity  of  venous  blood  nor- 
mally present.  It  requires  practice  and  careful  attention  to  detail 
to  apply  the  bandage  in  such  a  way  that  the  arteries  are  not  com- 
pressed, while  at  the  same  time  the  right  amount  of  venous  obstruc- 
tion is  obtained.     If  the  constriction  is  applied  properly,  the  veins 

Fig.   184. — Showing  the  method  of  applying  the  elastic  bandage  to  the  arm. 

in  the  part  distal  to  the  bandage  become  slightly  distended,  and  the 
part  takes  on  a  bluish-red  hue  and  becomes  warm  to  the  touch.  This 
degree  of  hyperemia  is  essential,  as  the  hot  hyperemia  only  has 
therapeutic  value.  As  already  emphasized  the  pulse  should  never  he 
obliterated.  It  must  at  all  times  be  distinguished,  not  even  weakened. 
Furthermore,  the  application  of  the  bandage  should  never  cause  pain 
or  annoyance,  or  hj^eresthesia  of  the  part.  If  too  great  a  degree  of 
compression  is  employed,  nutritional  disturbances  from  the  increased 
stasis  injures  the  tissues  and  reduces  their  natural  resistance.  In 
such  a  case,  a  white  edema  is  produced,  or  the  skin  becomes  grayish- 
blue  in  color,  or  has  a  mottled  red  and  white  appearance,  and  the  part 
remains  cold  to  the  touch.  Such  a  condition  demands  removal  of 
the  bandage  and  its  proper  reapplication. 


For  obtaining  the  proper  degree  of  hyperemia,  it  has  been  sug- 
gested that  a  sphygmomanometer,  such  as  the  Riva-Rocci  instru- 
ment, for  example,  be  employed.  The  cuff  is  secured  about  the  part 
in  the  same  manner  as  would  be  done  in  taking  the  blood-pressure 
and  the  systolic  pressure  is  estimated  (seepage  114).  The  mercury  is 
then  allowed  to  drop  about  10  mm.,  which  gives  the  proper  tension, 
after  which  the  tube  leading  to  the  inflation  band  is  tightly  clamped. 

In  chronic  cases  it  is  sometimes  very  difl&cult  to  obtain  the  proper 
amount  of  hyperemia,  and  several  procedures  have  been  advised  to 
increase  the  congestion.  Placing  the  part  in  a  bath  of  very  hot  water 
for  ten  minutes  before  the  constriction  is  applied  often  suffices.  In 
other  cases,  the  part  may  be  first  exsanguinated  by  means  of  an 
Esmarch  bandage,  as  would  be  done  preliminary  to  an  amputation, 
and  upon  removal  of  the  bandage  a  profuse  reactionary  flow  results, 
after  which  the  constrictor  is  applied. 

If  the  constriction  is  to  remain  in  place  for  long  periods  at  a  time, 
it  is  advantageous  to  apply  a  soft  flannel  bandage  beneath  the  rubber 
to  prevent  undue  pressure  upon  the  soft  parts,  which  might  produce 
an  irritation  of  the  skin,  or  even  atrophy  of  the  muscles.  This  is 
especially  necessary  when  treating  aged  or  thin,  flabby  individuals. 
While  the  bandage  is  in  place,  all  dressings,  splints,  etc.,  are 
removed  so  as  not  to  interefere  with  the  hyperemia.  If  open  wounds 
or  sinuses  be  present,  they  are  simply  covered  loosely  with  sterile  or 
antiseptic  gauze. 

A  marked  edema  results  from  the  hyperemia,  extending  up  to  the 
seat  of  constriction,  and  this  has  to  be  kept  within  proper  limits. 
When  the  application  is  only  for  short  periods  of  a  few  hours  each 
day,  the  edema  is  absorbed  spontaneously  in  the  intervals,  but  under 
prolonged  hyperemia  of  twenty  to  twenty-two  hours  the  time  for 
this  absorption  is  very  short,  and  it  is  often  not  possible  to  entirely 
reduce  it  between  applications.  Elevation  of  the  part  upon  pillows 
must  consequently  be  performed  during  the  intermissions.  Massage 
of  the  region  subjected  to  the  pressure  of  the  constriction  should  also 
be  practised  in  order  to  guard  against  pressure  atrophy. 

In  producing  hyperemia  of  the  shoulder-joint,  head  and  neck,  or 
testicles,  a  slight  variation  in  technic,  requiring  separate  description, 
is  necessary. 

Head  and  Neck. — About  the  neck  a  special  band,  already  de- 
scribed (page  2 10) ,  is  used.  It  should  be  applied  about  the  root  of  the 
neck,  well  below  the  larynx,  with  only  moderate  tension.  To  obtain 
the  greatest  degree  of  hyperemia  with  least  constriction,  small  pieces 


of  felt  or  wadding  may  be  placed  under  the  constricting  band  on 
either  side  of  the  larynx  over  the  great  veins  (Fig.  185).  If  properly 
applied,  such  a  bandage  can  be  worn  with  entire  comfort.  It  causes 
a  pronounced  edema  of  the  face,  particularly  about  the  eyelids.  This 
is  no  contraindication  to  its  use,  however.  Care  should  be  taken  not 
to  apply  the  band  too  tightly — of  course  it  should  never  strangulate 
or  interfere  with  eating  or  swallowing.  If  throbbing  or  a  feeling  of 
marked  fullness  in  the  head  is  complained  of,  the  bandage  should  be 
removed  and  reapplied. 

Shoulder. — A  soft  bandage  or  cravat  is  placed  loosely  about  the 
patient's  neck  and  tied.  Through  the  loop  a  stout  piece  of  rubber 
tubing  about  a  foot  in  length  is  passed  as  a  ligature  encircling  the 
shoulder-joint,  the  middle  portion  being  placed  in  the  axilla  and  the 

Fig.   185. — Showing  the  appUcation  of  the  neck  band. 

two  ends  passing  up — one  in  front  and  the  other  behind  the  joint — to 
a  point  above  the  shoulder,  where  they  are  secured  by  tying  or  by 
means  of  a  clamp.  A  second  piece  of  bandage  is  secured  to  the  tub- 
ing in  front  of  the  joint,  and  passes  across  the  chest,  under  the  opposite 
axiUa,  and  around  the  back,  where  it  is  secured  to  the  portion  of  the 
rubber  ring  behind  the  joint  (Fig.  186).  By  adjusting  the  bandage 
and  regulating  the  tightness  of  the  rubber  tubing,  the  proper  degree 
of  constriction  may  be  obtained. 

For  anatomical  reasons  it  is  not  possible  to  change  the  location  of 
the  constrictor  at  each  application,  as  is  done  upon  the  extremities, 
and  great  care  and  attention  is  necessary  to  avoid  pressure  necrosis. 
For  this  reason,  it  is  better  to  apply  the  constriction  for  short  periods 
— say  three  or  four  hours — at  a  time,  repeated  several  times  in  the 



twenty-four  hours,   with   correspondingly   longer   intermissions,   in 
preference  to  the  ten  or  eleven  hour  applications. 

Scrotum. — Tubercular  and  other  affections  of  the  testicle  may  be 
treated  by  means  of  constriction  about  the  root  of  the  scrotum.     A 

Fig.    i86. — Showing    the    method    of    obtaining    obstructive    hyperemia    of    the 


Fig.   187. — Showing  the  method  of  producing  obstructive  hyperemia  of  the  testicles. 

(After  Meyer-Schmieden.) 

small  piece  of  rubber  tubing  or  catheter  is  wound  several  times  about 
the  base  of  the  scrotum  over  a  layer  of  cotton  and  is  secured  in  place 
by  tying  with  a  piece  of  tape  or  cord  (Fig.  187). 


Hyperemia  by  Means  of  Suction  Cups. — Innumerable  forms 
and  styles  of  suction  cups  for  producing  hyperemia  in  regions  not 
accessible  to  constriction,  as  well  as  large  chambers  for  use  upon  the 
extremities  and  large  joints,  have  been  devised.  The  hyperemia 
produced  by  these  devices  is  also  a  venous  one,  and  is  applicable  to 
the  same  class  of  cases  as  is  obstructive  hyperemia  by  the  bandage. 
As  with  the  use  of  the  constricting  band,  exact  technic  is  necessary, 
and  the  importance  of  obtaining  the  proper  degree  of  hyperemia 
cannot  be  too  strongly  emphasized. 

When  one  of  the  cups  is  applied  to  a  surface  and  a  vacuum  pro- 
duced, the  skin  and  underlying  tissues  are  sucked  into  the  chamber 
and  venous  stasis  with  a  consequent  increase  in  the  supply  of  blood 
in  the  skin  and  deeper  layers  result.  Besides  producing  hyperemia, 
the  mechanical  effect  of  the  cupping  glass  is  also  of  distinct  advantage. 
From  an  open  discharging  wound  pus  and  broken-down  tissues 
are  rapidly  and  effectually  aspirated.  Small  sequestra  of  bone  are 
often  quickly  separated  and  discharged  through  a  sinas  under  the 
influence  of  the  hyperemia  combined  with  suction.  In  the  presence 
of  tubercular  sinuses,  daily  applications  of  the  suction  cups  may  be 
employed  in  conjunction  with  the  rubber  bandage. 

Apparatus. — Cups  suitable  for  furuncles,  styes,  carbuncles,  breast 
abscess,  etc.,  chambers  in  which  are  placed  the  fingers,  hands,  feet, 
and  large  joints,  as  well  as  apparatus  to  be  used  by  the  gynecologist, 
orthopedist,  otologist,  and  other  specialists  are  now  manufactured. 
Types  of  some  of  these  are  shown  in  the  following  illustrations  (Figs. 
188  to  198).  If  there  is  considerable  discharge,  a  type  of  cup  shown 
in  Fig.  189  will  be  found  most  useful. 

In  selecting  the  cup,  one  should  be  chosen  of  sufiiciently  large 
diameter  to  extend  well  outside  the  limits  of  an  acute  inflammation, 
and  with  edges  that  are  thick  and  smooth,  in  order  to  avoid  undue 
pressure  upon  the  skin.  In  the  smaller  glasses  the  suction  is  obtained 
by  means  of  small  rubber  bulbs.  With  the  larger  apparatus,  stronger 
suction  is  required  and  a  special  exhausting  pump  is  necessary  (Fig. 
199).  A  further  convenience  for  use  with  the  larger  apparatus  is  a 
three-way  stopcock  inserted  between  the  glass  chamber  and  the 
pump  to  allow  admission  of  air  when  the  negative  pressure  is  too 
great  or  is  to  be  discontinued. 

In  addition  to  these  cups  and  chambers,  larger  and  stronger  appa- 
ratus for  orthopedic  use  is  made  for  the  purpose  of  bending  stiff 
joints  by  atmospheric  pressure,  as  shown  by  Fig.  200.  Here  the  arm 
is  drawn  firmly  in  the  glass  case  as  the  air  is  exhausted  until  the  hand 


bier's  hyperemic  treatment 

meets  the  obstacle  at  the  lower  end  of  the  chamber,  when  the  wrist 
turns  in  the  direction  of  least  resistance.     Other  joints  of  the  body 

Fig.  198. 

Fig.  188. — Cup  for  sty.  189.  Cup  for  small  abscess.  190.  Cup  for  large 
abscess.  191.  Cup  for  gums.  192.  Cup  for  carbuncle.  193.  Cups  for  ton- 
sils. 194.  Breast  cup.  195.  Cup  for  cervix.  196.  Cup  for  nose.  19 7- 
Finger  suction  glass.      198.     Hand  suction  glass. 

may  be  similarly  treated  by  the  use  of  suitable  apparatus.  Klapp 
has  also  devised  metal  chambers  which  are  provided  with  an  air 
pump  and  a  heavy  rubber  bag  for  obtaining  motion  in  a  partially 


ankylosed  joint.  Upon  exhausting  the  air  in  the  apparatus,  the 
rubber  bag  descends  and  exerts  an  evenly  regulated  pressure  upon 
the  part  to  be  treated,  as  shown  in  Fig.  201. 

Fig.   199. — Pump  for  producing  a  vacuum  in  the  larger  cups  and  suction  glasses. 

Asepsis. — In  using  suction  apparatus  in  the  neighborhood  of  open 
wounds  or  sinuses,  strict  asepsis  should  be  observed.  To  avoid  all 
danger  of  adding  to  the  infection,  the  cups  should  be  boiled  before 

Pig.  200. — Showing  the  method  of  obtaining  motion  in  a  stiff  wrist  by  the  aid  of 

passive  hyperemia. 

used.     They  should  be  again  boiled  and  well  cleaned  before  being 
put  away. 

Fig.  201. — Showing  the  method  of  obtaining  motion  in  a  stiff  knee-joint  by  the 
aid  of  passive  hyperemia. 

Duration  of  Application. — In  the  use  of  cups,  brief  applications 
often  repeated  are  essential.     Accordingly,  the  cup  is  applied  for  five 



minutes,  and  is  then  removed  for  an  interval  of  two  or  three  minutes, 
to  allow  the  congestion,  edema,  and  swelling  to  subside.  The  cup  is 
then  again  applied  for  five  minutes,  and  an  entirely  fresh  supply  of 
blood  with  bactericidal  properties  is  brought  to  the  part,  the  entire 
treatment  consuming  about  three-quarters  of  an  hour. 

Technic.— Pus,  if  present,  is  always  to  be  evacuated  by  means  of  a 
small  incision  or  puncture,  as  previously  described,  before  application 
of  the  suction  apparatus. 

To  apply  the  cup,  the  edges  of  the  glass  are  first  moistened  with 
vaselin,  to  avoid  leakage  of  air.     Gentle  pressure  is  then  made  on  the 

Fig.  202. — Showing  a  cup  applied  to  a  carbuncle. 

bulb,  and  the  cup  is  placed  over  the  affected  region,  care  being  taken  to 
use  a  cup  that  is  large  enough.  Upon  releasing  the  bulb,  the  air  in 
the  cup  is  partly  exhausted,  causing  the  area  covered  by  the  cup  to 
be  drawn  up  into  it,  and,  if  a  proper  amount  of  suction  is  exerted, 
the  cup  adheres  to  the  surface  and  a  pronounced  hyperemia  results 
(Fig.  202).  If  the  application  is  made  over  an  open  infected  wound, 
pus  will  be  drawn  out,  accompanied  by  some  blood. 

The  importance  of  obtaining  just  the  proper  degree  of  hyperemia 
has  already  been  strongly  emphasized  and  is  reiterated  here.  It 
must  be  remembered  that  the  suction  should  be  just  sufficient  to 
slightly  decrease  the  outflowing  blood  without  interfering  with  the 
inflow.  The  object  is  to  produce  a  reddish-blue  color  of  the  part. 
.1  distinct  blueness  or  mottling  of  the  skin,  or  complaint  of  pain  on  the 
part  of  the  patient,  indicates  too  great  an  amount  of  suction  and  requires 
ivithdrawal  and  reap  plication   of  the   cup.     Pain   should   never   be 



produced  even  in  acutely  inflamed  regions.  Sometimes  more  than 
one  application  of  the  cup  is  necessary  before  the  proper  degree  of 
hyperemia  is  obtained.  With  the  suction  pump,  the  degree  of 
hyperemia  may  be  more  nicely  regulated.  In  this  case,  the  cup  with 
the  edges  well  lubricated  is  simply  applied  to  the  affected  region, 
and  the  air  is  slowly  exhausted  until  the  proper  degree  of  hyperemia 
is  induced.  If  the  vacuum  is  produced  too  rapidly,  it  is  apt  to  cause 
some  pain.  Should  it  be  found  that  too  great  a  degree  of  suction  is 
produced,  the  stopcock  may  be  opened  slightly  and  air  allowed 
to  enter  the  chamber  until  the  desired  degree  of  congestion  is  attained. 
In  the  use  of  the  large  chambers,  such  as  are  employed  for  the 
treatment  of  a  hand  or  foot,  the  member  to  be  subjected  to  hj^eremia 
is  first  coated  with  soap  or  vaselin  so  that  the  rubber  sleeve  will  more 
easily  sHp  over  the  skin  and  at  the  same  time  leakage  of  air  may  be 
avoided.  The  patient  then  thrusts  the  arm  or  foot  into  the  appara- 
tus, and  the  rubber  sleeve  is  bandaged  securely  about  the  limb  with 
a  rubber  bandage  (Fig.  203).  A  partial  vacuum  is  then  produced. 
This  causes  the  part  to  be  drawn  more  deeply  into  the  chamber,  and 

Fig.  203. — Showing  a  suction  glass  applied  to  the  hand. 

some  care  will  be  necessary  to  avoid  injuring  the  limb  by  suddenly 
drawing  it  against  the  closed  end  of  the  apparatus.  A  distinct 
hyperemia  of  the  whole  part  within  the  chamber  is  thus  produced, 
which  may  be  increased  or  lessened  at  will  by  increasing  or  decreas- 
ing the  amount  of  air  in  the  apparatus. 

During  the  intermissions  between  applications,  the  congestion 
may  be  relieved  by  elevation  if  the  part  be  an  extremity.  Discharge 
or  secretions  from  open  wounds  or  sinuses  should  be  removed  be- 
tween applications  by  gentle  bathing  of  the  part  with  warm  sterile 
water  or  some  antiseptic  solution.  At  the  end  of  the  treatment  the 
whole  part  should  be  gently  bathed  with  warm  solution,  and  all 
loose  exudate  or  necrotic  tissue  removed  with  forceps  or  sterile  gauze. 
A  simple  wet  dressing  is  then  appUed.  At  the  next  sitting,  if  a  crust 
has  formed  over  the  opening  or  sinus,  it  is  gently  removed  with 
forceps  and  the  treatment  is  continued  as  outlined  above. 


The  suction  treatment  should  be  applied  daily  at  first.  The 
amount  of  pus  usually  rapidly  decreases  each  day,  first  becoming  less 
purulent  and  more  serous,  until  finally  only  a  little  serum  is  with- 
drawn with  each  application.  The  swelling  diminishes  and  the  part 
begins  to  regain  its  normal  appearance  and  dimensions.  As  the 
suppuration  decreases,  the  treatment  may  be  given  every  second  day, 
and  finally  every  third  day,  until  recovery  is  complete. 


The  active  or  arterial  form  of  hyperemia  is  produced  by  means  of 
dry  hot  air.  Any  portion  of  the  body  when  subjected  to  heat  be- 
comes red  and  hyperemic  through  local  increase  in  the  supply  of 
arterial  blood.  The  effects  of  hot-water  bags,  hot  compresses,  hot 
povdtices,  hot  sand,  etc.,  are  all  familiar  examples  of  active  hyperemia. 
Hot  air  in  a  dry  form,  however,  is  the  most  effective  means  for  in- 
ducing such  a  hyperemia  on  account  of  the  high  degree  of  heat  that 
can  be  borne  without  discomfort.  A  part  may  be  subjected  to  the 
influence  of  dry  hot  air  of  a  temperature  of  212°  F.  (100°  C.)  or  more 
without  danger  of  producing  a  burn  or  other  injurious  effects.  On 
the  other  hand,  moist  heat  of  a  temperature  of  125°  F.  (52°  C.)  is 
capable  of  doing  distinct  harm,  and  is  unbearable  even  for  short 

The  use  of  hot  air  as  a  therapeutic  agent  is  by  no  means  new, 
and  has  been  employed  with  varying  degrees  of  success  for  ages,  but 
the  methods  of  application  were  crude  and  often  unsatisfactory. 
Improvements  in  the  modern  baking  apparatus  have  placed  this 
method  upon  a  firm  basis,  and  properly  applied  in  certain  cases  active 
hyperemia  becomes  a  therapeutic  agent  of  distinct  value. 

Indications. — Active  hyperemia  has  a  solvent  and  absorbent 
action  upon  exudate^,  infiltrations,  adhesions,  etc.,  and  a  marked 
analgesic  effect,  causing  a  sensitive  part  to  become  less  so  or  to  be 
entirely  reUeved  soon  after  the  appHcation  is  begun.  It  thus  acts 
favorably  in  chronic  rheumatism,  chronic  arthritis,  chronic  synovitis, 
and  arthritis  deformans.  It  aids  greatly  in  promoting  the  absorption 
of  edemas  and  of  effusions  of  blood  into  the  soft  parts,  and  in  synovial 
sacs — as  in  traumatic  synovitis.  Other  affections  in  which  active 
hyperemia  has  given  good  results  are  neuralgia,  sciatica,  neuritis, 
lumbago,  gout,  varicose  veins,  varicose  ulcers,  etc. 

In  fractures  near  a  joint  with  painful  involvement  of  the  joint 
itself,  it  is  of  great  value  in  reducing  the  edema  and  at  the  same 



time  hastening  the  repair,  thus  increasing  the  chances  of  obtaining  a 
more  useful  hmb  through  the  abihty  to  perform  early  passive  motion. 
In  a  CoUes'  fracture,  for  example,  the  bones  should  be  properly  re- 
duced and  within  a  few  days  the  part  should  be  daily  subjected  to 
the  influence  of  heat.  After  ten  days  the  splint  may  be  discarded 
entirely,  unless  there  seems  a  likelihood  that  the  deformity  will  recur, 
and  the  hot-air  treatment  is  daily  continued,  with  the  addition  of 
both  active  and  passive  motion. 

Fig.  204. — Apparatus  for  applying  active  hyperemia  to  the  hand  and  wrist  and  the 
method  of  its  application. 

While  active  hyperemia  is  of  distinct  therapeutic  value,  it  should 
not  be  employed  to  the  exclusion  of  other  means  of  treatment. 
Internal  medication  should  always  be  carried  out  when  the  condition 
is  such  that  it  seems  indicated,  and  the  hot-air  treatment  used  as  an 
adjunct.  In  affections  of  the  joints,  neuralgias,  etc.,  massage  should 
form  an  important  part  of  the  treatment.  Too  much  stress  cannot 
be  laid  on  the  value  of  massage  when  judiciously  used  in  the  ap- 
propriate class  of  cases. 

Apparatus. — Active  hyperemia  may  be  induced  either  by  the  use 
of  hot-air  boxes  or  hot-air  douches.  There  are  many  makes  of  hot- 
air  boxes  on  the  market.  The  simplest  are  made  of  cotton-wood 
carefully  fitted  together  and  covered  with  cloth  to  prevent  any  leakage 
of  air.     They  are  provided  with  a  lid  and  have  openings  at  one  or 



both  ends  for  receiving  a  limb.  These  openings  are  lined  with  cuffs 
of  felt  to  avoid  any  danger  of  burning  the  skin,  and  are  provided  with 
straps  so  that  the  cuffs  may  be  securely  fastened  to  a  limb.  Open- 
ings for  hot  air  are  provided  on  both  sides  of  the  box,  the  one  not  in 
use  being  shut  by  a  slide.  Into  one  of  these  a  chimney  is  fitted 
through  which  the  hot  air  is  conducted  from  the  heating  apparatus. 
The  heat  is  supplied  by  an  alcohol  lamp  or  a  gas  burner  secured  to  a 
bracket  so  that  the  lamp  may  be  raised  or  lowered  at  will.  The  lids 
have  one  or  more  openings  for  ventilation  of  the  apparatus.     The  air 

-^     ^ 

Fig.  205. — The   hot-air  douche  being   applied  in   sciatica.      (The  nozzle   of  the 
apparatus  should  be  shown  directed  more  to  the  posterior  surface  of  the  limb.) 

is  thus  constantly  in  motion,  which  is  important  in  order  to  permit 
evaporation  of  the  perspiration  upon  the  part  and  to  maintain  the 
dryness  of  the  air,  A  thermometer  is  also  provided  with  each  box 
for  indicating  the  temperature.  Such  boxes  are  made  to  fit  various 
parts  of  the  body,  as  the  arm,  hand,  shoulder,  foot,  knee,  hips,  etc. 

Hot-air  douches  may  also  be  obtained  for  use  over  small  areas,  as 
along  the  course  of  a  nerve,  about  the  ear,  etc.  The  douche  consists 
of  a  long  metal  movable  chimney,  underneath  which  is  the  lamp  or 
gas  burner  (Fig.  205). 

Temperature. — The  degree  of  heat  to  which  the  part  is  subjected 
may  vary  from  150°  F.  to  212°  F.  (60°  C.  to  100°  C.)  or  even  higher. 
The  temperature  must  never  be  high  enough,  however,  to  cause  dis- 


comfort,  and  the  patient's  feelings  should  be  the  guide.  It  should  be 
remembered  that  the  prolonged  application  of  a  very  high  degree  of 
heat  lowers  the  sensibility  of  a  part,  and  great  care  must  be  taken  not 
to  burn  the  patient;  the  same  caution  must  be  observed  when  apply- 
ing active  hyperemia  to  tissues  with  lowered  resistance.  A  moderate 
temperature  should  be  employed  at  the  start,  and  this  should  be 
increased  gradually  as  tolerance  is  attained.  The  temperature  is 
regulated  by  raising  the  lamp  nearer  the  box  or  moving  it  farther 
away,  and  also  by  the  size  of  the  flame. 

Duration  of  Applications. — The  heat  should  be  applied  from  half 
an  hour  to  an  hour  daily,  or  on  alternate  days.  In  exceptionally 
stubborn  cases  it  may  be  applied  for  the  same  length  of  time  twice 

Technic. — The  patient  assumes  a  comfortable  attitude,  either 
seated  or  lying  down,  with  the  apparatus  close  at  hand.  The  part 
to  be  baked  is  then  placed  in  the  box  and  the  lid  is  closed.  The  lighted 
lamp  is  placed  under  the  funnel  and  the  temperature  is  gradually 
raised  until  a  degree  of  heat  is  attained  that  can  be  comfortably  borne 
by  the  patient.  The  vent  in  the  top  of  the  apparatus  should  always 
be  open  when  it  is  in  use,  in  order  to  obtain  the  necessary  draught  for 
the  flame  and  proper  ventilation  of  the  apparatus.  When  the  desired 
degree  of  temperature  has  been  reached,  it  should  be  maintained  from 
half  an  hour  to  an  hour.  The  light  is  then  extinguished  and  the 
temperature  is  allowed  to  slowly  fall  before  the  member  is  removed. 
A  sudden  change  of  temperature,  such  as  would  be  occasioned  by 
immediately  removing  the  part  to  the  outside  atmosphere,  is  to  be 
avoided.  The  part,  when  removed  from  the  baking  apparatus,  is 
hot  and  hyperemic  and  remains  so  for  some  little  time.  Immediately 
following  the  treatment,  gentle  massage  and  passive  motion,  if 
indicated,  should  be  practised. 


The  injection  of  a  mixture  of  bismuth  and  vaselin  for  the 
diagnosis  and  treatment  of  fistulae,  tubercular  sinuses,  and  abscess 
cavities  was  devised  by  Beck  of  Chicago.  He  originally  employed 
the  method  for  the  purpose  of  determining  the  size,  course,  and  ex- 
tent of  fistulous  tracts.  His  first  injection  of  a  fistula  for  diagnostic 
purposes  resulted,  however,  in  the  prompt  closure  of  the  sinus,  and 
led  him  to  extend  the  use  of  the  injections  to  curative  purposes  with 
most  favorable  results. 



For  diagnostic  purposes  the  fistula  or  abscess  cavity  is  filled  with 
the  bismuth  mixture  and  then  a  radiograph  is  taken.  As  the  bis- 
muth offers  great  resistance  to  the  penetration  of  the  X-rays,  a  clear 
shadow  is  obtained  of  the  fistula  and  all  its  ramifications.  This 
gives  much  more  information  than  the  usual  methods  of  probing  and 
injecting  colored  fluids,  peroxid,  etc. 

As  a  therapeutic  measure  the  method  of  application  is  equally 
simple,  the  bismuth  paste  being  injected  into  the  fistula  or  abscess 
cavity  and  allowed  to  remain  there.  Later  it  is  absorbed.  It 
is  claimed  that  the  bismuth  has  a  bactericidal,  chemotactic,  and 
astringent  action  on  the  tissues.  Furthermore,  through  its  me- 
chanical effect,  it  promotes  healing  by  keeping  the  walls  of  the  sinus 
separated  and  forming  a  framework  for  the  granulating  tissue  to 
work  through.  The  method  is  applicable  to  all  fistulae  or  abscess 
cavities  except  biliary  or  pancreatic  fistulae  and  those  communicating 
with  the  cranial  cavity  or  urinary  bladder.  It  is  contraindicated 
in  acute  processes  and  new  sinuses,  as  absorption  occurs  very  readily 

Fig.   206. — Types  of  syringe  for  bismuth  paste  injections. 

from  the  fresh  lining  of  the  walls.  In  old  sinuses  and  abscess  cavities 
this  is  not  the  case,  the  thick  fibrous  walls  possessing  a  greatly  dimin- 
ished power  of  absorption. 

Toxic  effects  have  been  observed  after  the  use  of  bismuth  paste, 
and,  in  some  instances,  death  has  resulted.  The  symptoms  are  those 
of  nitrite  poisoning:  black  lines  upon  the  gums,  ulcerative  stomatitis, 
vomiting,  diarrhea,  albuminuria,  cyanosis,  and  collapse.  To  avoid 
this  danger  not  more  than  100  gm.  (3  ounces)  of  the  mixture  should 
be  injected  the  first  time,  and  the  patient  should  be  carefully  watched 
for  the  appearance  of  any  toxic  symptoms.  Should  they  develop 
the  cavity  must  be  promptly  evacuated.  This  may  be  accomplished 
by  injecting  into  the  cavity  some  warm  sterile  olive  oil  and  removing 
it  within  twenty-four  to  forty-eight  hours  by  aspiration.  The 
cavity  should  never  be  curetted,  as  this  simply  opens  up  new  chan- 
nels for  absorption. 


Apparatus.— There  will  be  required  a  vessel  to  heat  the  bismuth 
mixture  in,  a  glass  rod  to  stir  the  mixture,  and  a  large  blunt-pointed 
glass  syringe  with  asbestos  packing.  For  injecting  rectal  fistula 
Beck  has  devised  a  syringe  with  a  nozzel  of  special  shape  and  curve 

(Fig.  206). 

'  Formulary. — Two  mixtures  are  used  by  Beck: 

No.  I.    Bismuth  subnitrate,  33% 

Vaselin,  67% 

No.  II.  Bismuth  subnitrate,  30% 

White  wax,  5% 

Soft  paraffin  (120°  F.  melting  point),  5% 

Vaselin,  60% 

Formula  No.  I  is  used  for  diagnostic  purposes  and  for  early  treat- 
ments, while  No.  II  is  used  for  late  treatments  after  the  discharge 
from  the  sinus  has  ceased.  Only  arsenic-free  bismuth  should  he  used. 
The  paste  is  mixed  by  melting  the  vaselin  and  while  still  hot  stirring 
into  it  the  bismuth.  It  is  claimed  that  the  efiiciency  of  the  paste  is 
increased  by  adding  1/2  to  i  per  cent,  formalin. 

To  avoid  the  dangers  of  nitrite  poisoning,  various  other  substances 
have  been  incorporated  in  the  vaselin,  such  as  the  subcarbonate, 
oxychlorid,  and  subgallate  of  bismuth,  chalk,  oxid  of  iron,  etc., 
but  in  the  opinion  of  Beck  they  are  inferior  to  bismuth  subnitrate  for 
therapeutic  purposes. 

Asepsis. — The  syringe  and  receptacle  for  warming  the  bismuth 
mixture  and  the  stirring  rod  should  be  sterilized  by  dry  heat.  If  the 
syringe  needs  lubricating  the  packing  may  be  dipped  in  sterile  olive 
oil.  The  paste  is  sterilized  by  heating  over  a  water  bath,  care  being 
taken  not  to  allow  any  water  to  come  in  contact  with  the  mixture. 

Preparations  of  the  Patient. — No  general  preparation  of  the  pa- 
tient is  necessary;  the  sinus  or  cavity  to  be  injected  may  be  dried 
out  by  means  of  a  strip  of  gauze  if  this  is  feasible,  but  no  irrigation 
should  be  attempted.  The  opening  of  the  sinus  is  carefully  wiped  off 
with  alcohol. 

Technic. — The  paste  is  heated  over  a  water  bath  and  is  stirred 
until  thin  enough  to  be  drawn  into  the  syringe.  The  syringe  is  then 
filled  with  the  melted  mixture,  the  point  of  the  syringe  is  pressed 
closely  into  the  mouth  of  the  sinus,  and  the  mixture  is  injected  under 
sufiicient  pressure  to  distend  and  penetrate  all  the  ramifications  of 
the  sinus.  Both  for  purposes  of  diagnosis  and  treatment  it  is 
absolutely  essential  that  the  paste  be  made  to  enter  all  portions  of 
the  tract.  When  the  patient  feels  a  sense  of  distention  from  the 

2  26  bier's  hyperemic  treatment 

injection,  the  latter  is  stopped  and  a  pledget  of  gauze  is  quickly  placed 
over  the  opening.  An  ice-bag  is  then  applied  to  the  part  and  the 
patient  is  kept  quiet  for  a  few  hours. 

As  a  rule,  after  the  first  injection,  the  secretions  change  in  char- 
acter and  become  first  seropurulent,  then  serous,  and  finally  cease. 
Should  the  discharge  continue  the  injection  may  be  repeated  at  the 
end  of  a  week  and  after  that  every  three  to  five  days  until  the  sinus 
closes.  If  any  improvement  is  going  to  take  place  it  should  be 
noticed  inside  of  a  month.  Tracts  that  show  no  disposition  to 
close  should  be  carefully  examined  for  the  presence  of  dead  bone 
or  other  foreign  body,  which,  if  present,  must  be  removed.  A  small 
per  cent,  of  the  cases  show  no  results  at  all  from  the  treatment. 



With  the  present-day  refinements  of  laboratory  methods,  the  aid 
furnished  by  an  examination  of  discharges,  blood,  urine,  sputum, 
etc.,  is  of  great  importance,  and  often  without  the  information  so 
obtained  a  correct  diagnosis  is  impossible.  It  is  not  within  the  scope 
of  this  work  to  enter  into  the  details  of  laboratory  methods — these 
may  be  found  in  books  devoted  to  the  subject — but  it  is  the  writer's 
purpose  in  this  section  to  give  brief  instructions  as  to  the  methods  of 
collecting  material  and  the  preparation  of  specimens  for  subsequent 
pathological  examination.  This  work  usually  falls  to  the  lot  of  the 
practitioner  or  surgeon  himself,  and  often,  through  faulty  technic 
in  the  inoculation  of  a  culture,  in  the  preparation  of  slides,  or  in  the 
collection  of  discharges,  etc.,  the  results  of  the  pathologist's  examina- 
tion are  misleading  or  useless. 

In  any  case  where  material  is  sent  to  a  laboratory  for  examination, 
each  specimen  should  be  clearly  labeled  with  the  name  of  the  patient, 
or  by  a  distinguishing  number,  with  the  clinical  diagnosis,  and  a  short 
cHnical  history  of  the  case,  together  with  a  statement  of  from  what 
part  of  the  body  or  from  what  organ  the  growth,  discharge,  or  what-  may  be,  was  obtained,  should  accompany  the  specimen.  If 
chemicals  have  been  employed  for  preserving  the  specimen,  this 
should  also  be  stated  on  the  slip  sent  to  the  pathologist. 


Equipment. — A  number  of  clean  glass  sHdes,  sterile  swabs,  and 
suitable  specula  for  exposing  to  view  deep-seated  regions  from  which 
the  discharge  may  originate,  will  be  required. 

The  slides  should  be  absolutely  clean  and  free  from  grease. 
Unless  the  sKdes  are  very  dirty,  the  following  method  of  cleansing 
the  glass  will  suffice:  First  wash  off  the  sHde  with  soap  and  water, 
then  wipe  with  alcohol  and  ether  and  rub  dry  with  an  old  linen  or 
silk  cloth ;  finally  pass  the  slide  through  an  alcohol  flame.     When  once 




cleansed,  care  should  be  taken  that  the  surface  of  the  slide  does  not 
come  into  contact  with  the  skin,  as,  if  it  does,  a  thin  tilm  of  grease 
will  be  left  upon  the  glass. 

The  swabs  consist  of  steel  wires  or  applicators  about  one  extremity 
of  which  some  cotton  is  wound.  They  may  be  obtained  sterilized 
and  ready  for  use,  or  may  be  easily  extemporized  as  follows:  A  test- 

FlG.   207. — Roughened  wire  for  making  a  swab. 

tube  and  a  piece  of  stiff  wire,  of  a  length  somewhat  longer  than  that 
of  the  tube,  are  obtained.  One  end  of  the  wire  is  first  roughened  with 
a  file  (Fig.  207)  and  is  then  tightly  wrapped  with  a  small  roll  of 
cotton  (Fig.  208).  The  swab  is  then  loosely  laid  in  the  test-tube  and 
the  mouth  of  the  tube  is  plugged  with  sterile  cotton  (Fig.  209),  and 

Fig.  208. — Showing  the  method  of  wrapping  cotton  on  the  end  of  a  wire. 

the  whole  is  sterilized  by  dry  heat.     A  supply  of  swabs  may  be 
prepared  in  this  way  and  be  kept  ready  for  use  almost  indefinitely. 

Technic. — The  slides  are  arranged  upon  a  towel  and  the  tubes 
containing  the  sterile  swabs  are  placed  near  at  hand.  With  the  seat 
of  the  disease  well  exposed,  the  swab  is  removed  from  the  glass 
container  and  dipped  into  the  pus  or  the  secretion,  care  being  taken 

Fig.   209. — Sterile  swab  in  a  glass  test-tube. 

that  it  touches  nothing  but  the  material  from  which  the  specimen  is 
to  be  obtained.  The  swab  is  then  rubbed  over  the  surface  of  one 
of  the  glass  slides  so  as  to  spread  the  material  in  a  thin  transparent 
film  (Fig.  210).  At  least  two  smears  should  be  made  from  each 
locality,  and  each  slide  should  be  labeled  with  a  distinguishing  number. 
The  slides  are  allowed  to  dry  and  are  then  piled  up  and  secured  one 


upon  another,  but  with  their  surfaces  separated  by  matches  or  tooth- 
picks, as  shown  in  Fig.  211. 

Fig.  210. — Method  of  making  a  smear. 

From  the  Mouth  and  Pharynx. — Equipment. — Sterile  swabs, 
glass  slides,  and  a  tongue  depressor  will  be  required  (Fig.  212.) 

Fig.  211. — Glass  slides  separated  by  match  sticks  and  held  together  with  rubber 
bands  ready  for  shipment  to  the  laboratory.      (Ashton.) 

Technic. — It  should  be  seen  that  no  antiseptic  mouth  washes  or 
gargles  have  been  used  for  at  least  two  hours  previous  to  the  time  the 
smear  is  made.     The  patient  is  seated  in  a  good  light,  with  his 

Fig.  212. — Instruments  for  taking  a  smear  from  the  pharynx,      i,  Sterile  swabs; 
2,  glass  slides;  3,  tongue  depressor. 

mouth  widely  opened,  and  the  tongue  controlled  by  the  tongue  de- 
pressor held  in  the  operator's  left  hand,  so  that  a  good  view  of  the 



diseased  area  may  be  obtained.  The  sterile  swab  is  then  removed 
from  its  container,  taken  in  the  right  hand,  and  is  passed  into  the 
mouth,  the  operator  being  careful  not  to  allow  it  to  come  in  contact 
with  the  lips  or  tongue.  When  in  contact  with  the  area  from  which 
the  material  is  to  be  obtained,  the  swab  should  be  rotated  about  so 
as  to  bring  as  much  as  possible  of  its  surface  in  contact  with  the 
secretions  (Fig.  213).  In  removing  the  swab  the  same  care  against 
contamination  from  contact  with  the  tongue,  etc.,  should  be  observed. 

Fig.  213. — Showing  the  method  of  taking  a  smear  from  the  pharynx. 

A  thin  smear  is  then  made  upon  a  slide  in  the  manner  described  above, 
and  the  swab  is  returned  to  its  container  for  future  inoculation  of 
culture  tubes  if  necessary. 

From  the  Nose. — Equipment. — Swabs,  slides,  a  nasal  speculum, 
a  head  mirror,  and  an  angular  pipette  (Fig.  214)  will  be  required. 

Technic. — Ordinarily,  for  microscopical  examination,  a  smear 
made  in  the  usual  way  from  secretions  blown  from  the  nose  into  a 
clean  handkerchief  is  sufficient.  If,  however,  it  is  desired  to  obtain 
a  smear  from  any  one  locaUty,  the  secretion  should  be  first  removed 
by  means  of  a  pipette  (page  243),  and  from  this  the  smear  is  made. 

From  the  Eyes. — Equipment. — Slides,  a  sterile  swab,  a  platinum 
needle,  and  an  alcohol  lamp  (Fig.  215)  will  be  necessary. 

Technic. — There  should  be  no  preliminary  cleansing  of  the  eyes. 
The  platinum  needle  is  first  sterilized  by  passing  it  through  the 



flame,  and  when  it  has  cooled  the  hds  are  separated,  the  loop  is 
brought  into  contact  with  the  pus  and  some  of  it  is  transferred 
to  a  slide.    A  smear  is  then  made  by  means  of  the  swab. 

Fig.  214. — Instruments   for  taking  a  smear  from  the  nose,     i,  Sterile  swab;  2, 
nasal  speculum;  3,  glass  slides;  4,  angular  pipette;  5,  head  mirror. 

From    the    Urethra. — Equipment. — Slides    and    sterile   swabs 
(Fig.  216)  should  be  provided. 

Technic. — In  a  male,  the  meatus  should  be  cleansed,  and  a  drop 

Fig.  215. — Instruments  for  taking  a  smear  from  the  eyes,      i,  Sterile  swab;  2, 
glass  slides;  3,  alcohol  lamp;  4,  platinum  needle. 

of  pus  is  expressed  by  stripping  the  urethra  with  the  finger  from 
behind  forward.  The  swab  is  then  dipped  in  the  pus  and  a  thin 
smear  is  made  upon  a  slide  in  the  usual  way. 



Fig.  2i6. — Instruments  for  taking  a  smear  from  the  urethra,      i,   Sterile  swab; 

2,  slides. 

Fig.  217. — Forcing  the  discharge  out  of  the  urethra  b}^  pressure  against  the  canal 
with  the  tip  of  the  finger  in  the  vagina.      (Ashton.) 


In  the  female,  the  labia  are  held  apart  by  an  assistant,  the  index 
finger  is  inserted  in  the  vagina,  and  the  urethra  is  stripped  from 
behind  forward  (Fig.  217).  The  swab  is  then  brought  into  contact 
with  the  drop  of  pus  that  is  thus  expressed,  and  a  smear  is  made 
from  it  in  the  usual  way. 

From  the  Vagina. — Equipment. — Swabs,  slides,  and  a  vaginal 
speculum  (Fig.  218)  are  needed. 

Technic. — The  labia  are  separated  and  the  speculum  is  introduced 
so  as  to  obtain  a  good  view  of  the  parts.     The  swab  is  then  introduced 

Pig.  218. — Instruments  for  taking  a  smear  from  the  vagina,      i     Sterile  swab; 
2,  glass  slides;  3,  vaginal  speculum. 

without  touching  the  vulva  and  is  rubbed  in  the  discharge,  mucous 
patch,  or  whatever  it  may  be.  A  smear  is  then  made  from  the 
material  thus  obtained. 

From  the  Cervix. — Equipment. — A  long  swab,  a  speculum,  two 
tenacula,  a  sponge  holder,  and  glass  slides  (Fig.  219)  should  be 

Technic. — The  speculum  is  introduced  so  that  the  cervix  is  well 
exposed  to  view,  and,  by  means  of  a  tenaculum  placed  in  each  lip, 
the  cervix  is  drawn  as  far  down  as  possible.  The  swab  is  then  passed 
into  the  cervical  canal  (Fig.  220),  but  care  is  taken  that  it  does  not 
enter  the  uterus  for  fear  of  carrying  infection  to  what  may  be  a  healthy 
organ  from  a  diseased  cervix.  The  swab  is  then  withdrawn,  and 
a  smear  is  made  in  the  usual  way. 



Fig,  219. — Instruments  for  taking  a  smear  from  the  uterus.      I,  Sterile  swab; 
2,  tenacula;  3,  Simon's  speculum;  4,  glass  slides;  5,  sponge  holder. 

Fig.  220. — Method  of  collecting  the  secretions  from  the  uterus.     (Ashton.) 



Equipment. — Culture  tubes,  sterile  swabs,  platinum  needles, 
thumb  forceps,  and  an  alcohol  lamp  (Fig.  221)  will  be  required. 

A  variety  of  media  are  employed  for  the  growth  of  bacteria,  such 
as  broth,  agar-agar,  gelatin,  and  blood  serum,  according  to  the  kind 
of  bacteria  to  be  cultivated.     The  culture  media  are  sold  in  sterile 

3i    Lm 



Fig.  221. — Instruments  for  making  a  culture,      i,   Alcohol  lamp;  2,  thumb 
forceps;  3,  sterile  swabs;  4,  culture  tubes;  5,  platinum  needle. 

test-tubes,  generally  plugged  with  cotton.  When  they  are  to  be 
kept  for  any  length  of  time,  the  tubes  should,  in  addition,  be  sealed 
with  rubber  caps  or  oiled  paper  to  prevent  their  contents  from  drying 

The  inoculation  of  the  tubes  is  performed  by  means  of  a  swab 
or  a  platinum  needle.     The  method  of  making  and  sterilizing  the 

Fig.   222. — Platinum  needles. 

former  has  been  described  above  (page  228).  The  needle  consists 
of  a  platinum  wire,  3  to  4  inches  (7.5  to  10  cm.)  long,  which  is  in- 
serted into  the  end  of  a  glass  rod  6  to  8  inches  (15  to  20  cm.)  long, 
which  serves  as  a  handle.  The  free  end  of  the  wire  may  be  made 
into  the  form  of  a  loop  or  it  may  be  simply  left  straight  (Fig.  222), 



according  to  whether  a  streak  or  a  stab  culture  is  to  be  made.  Before 
use,  the  wire  should  be  sterilized  by  passing  it  back  and  forth  through 
a  flame  for  a  few  seconds. 

Technic. — In  making  a  culture  the  greatest  care  must  be  exer- 
cised as  to  the  asepsis  and  the  avoidance  of  contamination.  The 
culture  tubes,  platinum  needles,  etc.,  are  arranged  upon  a  towel 
within  easy  reach,  and  the  alcohol  lamp  is  lighted.  The  end  of  the 
culture  tube  containing  the  cotton  plug  is  first  passed  through  the 
flame,  the  cotton  being  singed  so  as  to  destroy  any  germs  that  may 
be  deposited  upon  it  (Fig.  223).  The  culture  tube  is  held  between 
the  thumb  and  forefinger  of  the  left  hand,  with  the  mouth  of  the 

Fig.  223.-:-Singeing   the   cotton    stopper   of   a   culture   tube   preparatory   to   its 


tube  pointing  downward,  if  it  contains  a  solid  medium,  so  as  to  pre- 
vent the  entrance  of  any  dust.  A  pair  of  thumb  forceps,  after  being 
passed  through  the  flame,  are  used  to  remove  the  cotton  plug  which 
is  then  transferred  to  the  left  hand  where  it  is  held  between  the  index 
and  second  fingers  while  the  culture  is  being  made. 

If  a  streak  culture  is  to  be  made,  a  looped  platinum  needle  is 
sterilized  by  passing  it  through  the  flame,  including  the  portion  of 
glass  handle  that  will  enter  the  tube,  and,  after  permitting  it  to  cool, 
the  tip  of  the  needle  is  dipped  into  the  secretion  or  pus — care  being 
taken  that  it  touches  nothing  else — and  is  passed  to  the  bottom  of 
the  culture  tube  and  then  gently  withdrawn  over  the  culture  medium 
so  as  to  spread  the  material  in  a  thin  streak  upon  its  sloping  surface 
(Fig.  224).     The  platinum  needle  is  again  passed  through  the  flame 



and  is  then  laid  aside.  The  tube  is  finally  closed  with  the  cotton 
plug,  fijst  singeing  the  cotton,  however,  in  the  flame  while  held  with 
the  thumb  forceps. 

Fig.  224. — Alethod  of  making  a  streak  culture.      (Levy  and  Klemperer.) 

Fig.  225. — Showing  "a"  stab  culture,  and  "b"  smear  culture. 

When  a  stab  culture  is  to  be  made,  a  straight  needle  is  employed 
instead  of  a  looped  one.  The  technic  is  precisely  the  same  as  for  a 
streak  culture  except  that  the  needle  is  inserted  straight  into  the 
culture  medium  and  is  then  withdrawn. 


A  smear  culture  with  a  swab  is  made  as  follows:  The  culture  tube 
and  the  tube  containing  the  sterile  swab  are  held  side  by  side  between 
the  thumb  and  the  index  finger  of  the  left  hand.  The  cotton  plugs 
are  removed  with  sterile  forceps,  the  ends  of  the  tubes  and  the  ex- 
posed cotton  being  first  singed,  as  described  above.  The  cotton 
plugs  are  held  between  the  ring  and  little  finger  and  the  ring  and 
middle  fingers  of  the  left  hand,  while,  with  the  right  hand,  the  swab 
is  withdrawn  from  its  tube,  dipped  in  the  secretion,  and  is  then  in- 
serted into  the  culture  tube  and  is  rubbed  thoroughly  over  the  surface 
of  the  culture  medium  (Fig.  226).  The  swab  is  then  replaced  in  its 
container  and  the  cotton  plug  is  singed  and  reinserted  into  the  mouth 
of  the  culture  tube. 

When  a  number  of  cultures  are  being  made,  care  should  be  taken 
to  immediately  number  each  tube  as  it  is  inoculated. 

Fig,  226. — The  method  of  making  a  smear  culture. 


When  in  the  absence  of  culture  tubes  or  for  other  reasons  it  is 
necessary  to  send  fluid  material  to  a  laboratory  for  bacteriological 
examination,  it  is  best  collected  in  sterile  glass  pipettes  which  are 
then  hermetically  sealed.  This  insures  against  leakage  as  well  as 
any  chance  of  contamination  during  transportation. 

Equipment. — A  number  of  glass  pipettes,  a  rubber  suction  bulb  or 
a  suction  syringe,  an  alcohol  lamp,  scissors,  and  suitable  specula  (Fig. 
227)  will  be  required. 



The  pipettes  may  be  easily  made  from  thin  glass  tubing  of  an  ex- 
ternal diameter  of  about  i/ 4  inch  (6  mm.).  The  center  of  a  piece  of 
such  tubing  about  6  inches  (15  cm.)  long  is  heated  over  a  flame,  the 

Fig.  227. — Apparatus  for  collecting  discharges  for  bacteriological  examination 
I,  Alcohol  lamp;  2,  scissors;  3,  suction  syringe;  4,  pipettes. 

tube  continually  being  turned  the  while,  until  the  glass  is  softened 
over  about  1/2  inch  (i  cm.)  of  space  (Fig.  228).  The  tubing  is  then 
removed  from  the  flame,  and,  while  the  glass  is  still  soft,  the  two  ends 
are  drawn  apart  so  that  the  softened  central  portion  is  stretched  out 

Fig.  228. — Heating  the  glass  tube  at  its  center  over  a  Bunsen  flame.     (Ashton.) 

into  a  capillar}-  tube  several  inches  long  (Fig.  229).  The  center  of 
this  capillary  tube  is  again  heated  in  the  flame  until  it  melts,  and,  by 
drav-ing  upon  the  ends,  it  parts  in  the  center,  leaving  two  pipettes, 



each  with  one  sealed  end  (Fig.  230).  The  center  of  the  thick  por- 
tions of  each  of  these  pipettes  is  then  melted  in  the  same  way  and  is 
drawn  out  into  a  capillary  tube  an  inch  (2.5  cm.)  or  more  long,  so 

Fig.  229.^ — The  glass  tube  is  shown  drawn  out  at  its  center.      (Ashton.) 

that  we  have  as  a  result  two  pipettes  each  drawn  to  a  point  at  one  end, 
wide  at  the  other,  and  between  the  two  ends  a  bulb  separated  from 
the  wide  end  by  a  capillary  constriction  (Fig.  231).     The  pipettes  are 

Fig.  230. — Fusing  apart  the  center  of  the  drawn-out  portion  of  the  tube.     (Ashton.) 

sterilized,  after  inserting  a  piece  of  cotton  wool  in  the  wide  ends,  by 
passing  the  whole  tube  through  the  flame  until  it  is  hot  (Fig.  232), 
but  not  so  hot  as  to  melt  the  glass  or  burn  the  cotton  plug.     Thus 

Fig.  231. — Making  a  bulbous  pipette  by  heating  the  thick  portion  and  drawing  it 
out  to  a  thin  tube.      (Ashton.) 

sterilized,  the  pipettes  may  be  kept  on  hand  ready  for  use  almost 

The  suction  for  drawing  up  secretions  into  the  pipettes  may  be 

Fig.  232. — Sterilizing  the  interior  of  the  bulbous  portion  (b)  and  the  slender  end 
(a)   of  the  pipette;   (d)  plug  of  cotton.      (Ashton.) 

furnished  by  the  bulb  of  a  medicine  dropper,  or  by  attaching  a  piece 
of  rubber  tubing  to  the  pipette  and  applying  the  lips  or  a  small  suc- 
tion syringe  to  the  free  end  of  the  rubber  tubing. 



Technic. — The  pipettes  are  arranged  near  at  hand  upon  a  towel, 
and  the  alcohol  lamp  is  lighted.  The  sealed  end  of  the  pipette  should 
be  cut  off  with  scissors  (Fig.  233)  and  should  be  then  rounded  off 

Fig.  233. — Snipping  off  the  fused  point  of  the  slender  end  (a)  of  the  pipette  with 

scissors.     (Ashton.) 

Fig.  234. — Rounding  off  the  rough  edges  of  the  glass  in  the  flame.     (Ashton.) 

smooth  in  the  flame,  so  as  to  avoid  producing  any  injury  to  the  tissue 
(Fig.  234). 

The  pipette  is  then  slowly  passed   through   the   flame  so  as 

Fig.  235. — Sterilizing  the  outer  surface  of  the  slender  end  (a)  of  the  pipette. 


Fig.  236. — Hermetically  sealing  the  secretions  in  the  bulbous  portion  of  the  pipette 
by  fusing  it  in  the  flame  at  a  and  c.     (Ashton.) 

to  sterilize  the  entire  outer  surface  of  the  tube  (Fig.  235).     When 
the  tube  has  cooled,  the  rubber  nipple  or  tubing  is  placed  upon  the 
large  end,  and  the  small  end  is  inserted  in  the  discharge  or  secretion. 



which  is  then  drawn  up  into  the  pipette  by  suction.  The  suction  bulb 
is  then  removed,  and  the  small  end  of  the  pipette  is  sealed  by  melting 
it  in  the  flame.  The  constricted  portion  is  likewise  melted  in  the 
flame,  and  the  portion  of  the  pipette  containing  the  cotton  wool  is 
removed,  and  the  remaining  end  of  the  pipette  is  sealed  (Fig.  236). 
In  this  way  the  discharge  is  hermetically  sealed  in  small  glass  tubes 
(Fig.  237)  and  can  be  sent  to  any  distance  for  later  bacteriological 

Fig.  237. 

-Showing  the  bulbous  portion  of  the  pipette  sealed  and  containing  the 
secretion.      (Ashton.) 

examination.     Each  tube  as  it  is  prepared  should  be  carefully  labeled 
with  a  distinguishing  number. 

From  an  Abscess  Cavity. — Care  must  be  taken  that  no  anti- 
septic irrigating  fluid  is  used  before  the  discharge  is  secured.  A 
specimen  should  be  obtained  free  from  blood,  if  possible.  To 
avoid  contamination,  the  first  portion  of  the  pus  should  be  allowed 

Fig.  238. — Instruments  for  obtaining  secretions  from  the  nose  for  bacteriological 
examination,  i,  Sterile  angular  pipette;  2,  alcohol  lamp;  3,  scissors;  4,  nasal 
speculum;  5,  head  mirror. 

to  escape;  the  edges  of  the  incision  are  then  separated  while  the 
pipette  is  inserted  into  the  cavity,  and  a  specimen  is  withdrawn 
from  its  depths. 

From  Serous  Cavities. — The  method  of  obtaining  fluid 
from  serous  cavities  is  described  under  exploratory  punctures  (Chap- 
ter XI). 



From  the  Nose  and  Accessory  Sinuses. — Equipment. — An 

angular  pipette  will  be  required,  as  well  as  an  alcohol  lamp,  scissors,  a 
nasal  speculum,  suitable  illumination,  and  a  head  mirror  (Fig.  238). 

The  angular  pipette  may  be  made  by  taking  a  straight  pipette 
■with  a  long  capillary  tube,  heating  the  latter  at  a  distance  of  about 
3  inches  (7.5  cm.)  from  its  extremity  and,  when  soft,  bending  it  to 
an  angle  of  135  degrees.  The  end  should  be  well  smoothed  off  in  a 
flame  before  using. 

Technic. — The  same  general  principles  as  outlined  above  are 
foUowed.  The  patient  is  seated  as  for  an  anterior  rhinoscopic  exami- 
nation (page  312),  the  nasal  speculum  is  introduced,  and  the  light  is 

Fig.  239. — Method  of  sucking  secretion  into  a  pipette  from  the  female  urethra 


reflected  so  that  the  interior  of  the  nose  can  be  clearly  observed. 
The  tip  of  the  pipette  is  then  inserted  until  it  comes  in  contact  with 
the  discharge,  care  being  taken  not  to  have  it  touch  the  mucous  mem- 
brane or  the  vibrissas  about  the  vestibule.  The  point  of  the  instrument 
is  moved  about  in  the  secretion  while  suction  is  exerted  and  some  of 
the  discharge  will  thus  be  withdrawn.  The  pipette  is  then  removed, 
sealed,  and  properly  labeled. 

From  the  Eyes. — The  technic  is  not  different  from  that  already 
described  for  collecting  discharges  from  other  regions,  and  no  special 
forms  of  pipettes  are  necessary.  Any  preliminary  cleansing  of  the 
eyes  should,  of  course,  be  avoided. 



From  the  Urethra. — Equipment. — Pipettes  and  the  other  ap- 
paratus necessary  for  collecting  discharges  (see  Fig.  227)  will  be 

Technic. — The  urine  should  not  be  voided  for  several  hours  prior 
to  obtaining  the  specimen.  The  urinary  meatus  is  first  exposed, 
and,  after  the  end  of  the  pipette  has  been  inserted  into  the  canal,  the 
secretion  is  sucked  into  the  pipette  (Fig.  239).  When  the  discharge 
is  scanty,  sufficient  may  be  obtained  by  expressing  the  pus  from  the 
posterior  portion  of  the  urethra  by  drawing  the  finger  along  the 
urethra  from  behind  forward.  In  the  female  the  same  method  may 
be  employed  with  the  index  finger  in  the  vagina  (see  Fig.  217). 
When  a  specimen  has  been  obtained,  the  ends  of  the  pipette  are 
sealed  and  the  tube  is  properly  labeled. 

Fig.  240. — Instruments  for  obtaining  secretions  from  the  vagina  for  bacterio- 
logical examination.  I,  Alcohol  lamp;  2,  scissors;  3,  suction  syringe;  4,  sterile 
pipettes ;  5,  vaginal  speculum. 

From  the  Vagina. — Equipment. — Pipettes,  a  suction  syringe 
and  rubber  tubing,  scissors,  an  alcohol  lamp,  and  a  vaginal  speculum 
(Fig.  240)  will  be  required. 

Technic. — The  labia  are  separated  and  the  speculum  is  introduced 
into  the  vagina,  so  that  the  posterior  cul-de-sac  is  exposed  to  view. 
The  distal  end  of  the  pipette  is  then  carefully  introduced  into  the  dis- 
charge, and  sufficient  secretion  for  the  purposes  of  the  examination  is 
withdrawn  by  means  of  suction.  The  pipette  is  then  removed, 
both  ends  are  sealed,  and  the  specimen  is  properly  labeled. 

From  the  Uterus. — Equipment. — Pipettes,  a  suction  syringe 
and  rubber  tubing,  scissors,  an  alcohol  lamp,  vaginal  specula,  two 
tenacula,  and  sponge  holders  (Fig.  241)  will  be  required. 


Technic. — The  speculum  is  introduced  into  the  vagina  and  the 
cervix  is  well  exposed  to  view.  Any  vaginal  secretions  are  removed 
by  means  of  sponges  on  holders,  tenacula  are  inserted  in  the  anterior 
and  posterior  lips  of  the  cervix,  and  the  latter  is  drawn  well  down. 
The  pipette  is  then  inserted  into  the  cervical  canal,  care  being  taken 
not  to  push  it  into  the  uterus,  and  the  secretion  is  sucked  into  it. 
It  is  then  withdrawn,  and  both  ends  are  sealed. 

Fig.  241. — Instruments  for  collecting  discharges  from  the  uterus  for  bacterio- 
logical examination.  (Ashton.)  i,  Pipettes;  2,  suction  syringe;  3,  Simon's 
speculum;  4,  tenacula;  5,  scissors;  6,  sponge  holder;  7,  alcohol  lamp. 


Blood  may  be  examined  microscopically  either  from  a  fresh 
specimen  or  from  a  dried  smear.  The  former  procedure  is  suitable 
only  when  the  blood  can  be  examined  promptly — say  within  half  an 
hour.  A  smear  is  made  when  the  morphology  of  the  cellular  ele- 
ments is  to  be  studied  after  being  properly  stained. 

Equipment. — Slides,  cover-glasses,  an  alcohol  lamp,  thumb  for- 
ceps, and  a  spear-pointed  needle  or  a  lancet  (Fig.  242)  are  necessary. 
The  cover-glasses  and  slides  should  be  of  the  best  material.  The 
former  should  be  very  thin  and  about  7/8  inch  (22  mm.)  square. 
Both  should  be  absolutely  clean  and  free  from  grease;  the  cleansing 
may  be  performed  after  the  method  described  on  page  227. 

Location  of  Puncture. — The  blood  may  be  withdrawn  from  a 
prick  in  the  lobe  of  the  ear  or  in  the  tip  of  the  finger.  The  former 
region  is  preferable,  however,  as  it  is  not  so  sensitive  as  the  finger, 



and  it  is  usually  cleaner,  so  that  the  chances  of  infection  are  less. 
Furthermore,  when  the  puncture  is  made  in  the  ear,  the  operation  is 
removed  from  the  view  of  the  patient,  which  is  an  important  con- 
sideration in  the  case  of  children  and  nervous  individuals. 




Fig.  242. — Instruments  for  collecting  blood  for  microscopical  examination. 
I,  Thumb  forceps;  2,  spear-pointed  needle;  3,  cover-glasses;  4,  glass  slides;  5. 
alcohol  lamp. 

Asepsis. — The  site  of  puncture  should  be  cleaned  by  first  rubbing 
it  with  a  wipe  wet  with  alcohol,  and  then  drying  it  with  ether.  The 
needle  or  lancet  is  sterilized  by  boiling  or  passing  it  through  a 

Fig.  243. — Making  a  fresh  blood  smear.     First  step,  puncturing  the  ear. 

Technic. — i.  Fresh  Specimen. — Care  should  be  taken  to  avoid 
chilling  the  specimen  and  exposing  it  to  the  air  any  longer  than  is 
necessary;  accordingly,  everything  should  be  in  readiness  for  the 


examination.  The  slide  is  warmed  over  the  alcohol  lamp  or  by 
vigorously  rubbing  it  with  a  piece  of  linen,  and  is  then  laid  on  a 
sterile  towel.  The  cover-glass  is  likewise  warmed  and  placed  near  at 
hand.  The  lobe  of  the  ear  is  grasped  between  the  thumb  and  fore- 
finger of  the  left  hand  and  with  a  quick  stab  the  lowest  portion  of  the 

Fig.  244. — Alaking  a  fresh  blood  smear.     Second  step,  collecting  the  drop  on  a 


lobe  is  punctured  (Fig.  243).  The  blood  should  be  allowed  to  flow 
■without  pressure  or  rubbing,  as  these  maneuvers  produce  a  hyperemia 
and  the  constituents  of  the  blood  may  be  changed  in  character  or 
the  blood  cells  may  be  deformed.     The  first  drop  is  wiped  away 

Pig.  245. — Making  a  fresh  blood   smear.     Third  step,   placing   the    cover-glass 
holding  the  blood  drop  on  a  slide. 

and  a  second  drop  is  allowed  to  flow.  The  cover-glass  is  then  taken 
up  in  the  thumb  forceps  and  is  applied  by  its  under  surface  to  the 
apex  of  the  drop  (Fig.  244),  but  is  not  allowed  to  touch  the  skin. 
The  cover-glass  is  then  gently  lowered  upon  the  w^armed  slide  (Fig. 
245)  and  the  drop  of  blood  is  thus  caused  to  spread  out  in  a  thin 



circular  layer  between  the  slide  and  the  cover-glass.  If  the  drop  is 
not  too  large,  the  blood  will  not  spread  beyond  the  margins  of  the 
cover-glass.  The  cover-glass  should  not  be  pressed  down  upon  the 
slide,  as  this  will  injure  the  corpuscles. 

2.  Dried  Specimen. — A  puncture  is  made  in  the  lobe  of  the  ear 

Fig.  246. — Method  of  making  a  drj'  blood  smear  with  two  slides. 

in  the  manner  described  above,  and,  after  the  first  drop  of  blood  has 
been  wiped  away,  the  second  drop  is  received  upon  a  slide  near  one 
end.  As  quickly  as  possible  the  edge  of  another  slide  is  dipped 
into  the  drop  thus  collected  and  is  drawn  along  the  surface  of  the 

Fig.  247. — Making  a  dry  blood   smear   with  two  cover-glasses.     Second  step, 
collecting  the  drop  on  a  cover-glass. 

first  slide,  spreading  out  the  drop  in  a  broad  thin  smear  (Fig.  246). 
To  be  of  any  value  the  smear  must  be  spread  out  evenly  and  thinly. 
A  second  method  is  to  employ  cover-glasses.  Two  cover-glasses 
are  thoroughly  cleansed  and  are  placed  conveniently  at  hand.  The 
ear  is  punctured  in  the  way  described  above  (see  Fig.  243),  and  the 


first  drop  of  blood  is  removed.  One  cover-glass  is  then  held  by  its 
sides  between  the  thumb  and  forefinger  of  the  right  hand,  while  the 
second  one  is  grasped  by  its  sharp  angles  in  the  fingers  of  the  left 
hand.  The  under  surface  of  the  first  cover  is  then  applied  to  the  apex 
of  the  drop  of  blood  (Fig.  247),  and  is  quickly  placed  upon  the  second 

Fig.  248. — Making  a  dry  blood  smear  with  two  cover-glasses.  Third  step,  the 
method  of  holding  the  two  cover-glasses  preparatory  to  placing  the  one  holding  the 
drop  upon  the  second  one. 

Pig.  249. — Making  a  dry  blood  smear  with  two  cover-glasses.  Fourth  step , 
showing  the  two  covers  with  their  surfaces  in  contact  and  the  drop  of  blood  spread 
out  in  a  thin  layer  between  them. 

Fig,  250. — Making  a  dry  blood  smear  with  two  cover-glasses.     Fifth  step,  showing 
the  method  of  drawing  the  two  covers  apart. 

glass,  with  the  angles  of  the  two  not  coinciding  (Fig.  248),  so  that  the 
drop  spreads  out  by  its  own  weight  in  a  thin  film  between  the  two 
covers  (Fig.  249).  If  too  large  a  drop  is  taken,  the  upper  cover  will 
simply  float  around  upon  the  lower.     The  upper  cover  is  finally 



seized  between  the  thumb  and  forefinger  of  the  right  hand  and,  still 
holding  the  lower  cover  in  the  left  hand,  the  two  covers  are  shd  apart 
in  the  same  plane  (Fig.  250).  Unless  too  small  a  drop  has  been 
taken,  this  is  readily  accomplished.  The  films  thus  obtained  are  then 
allowed  to  dry,  and  later  they  may  be  fLxed  and  properly  stained.  It 
is  always  well  to  make  three  or  four  of  these  smears,  as  some  of  the 
films  may  be  poorly  spread,  or  may  be  broken  in  handling. 


The  best  method  of  securing  blood  for  culture  is  by  a  venous  punc- 
ture. The  ordinary  method  of  obtaining  blood  through  a  prick  of 
the  ear  or  of  the  finger  is  worthless  for  bacteriological  purposes  on  ac- 
count of  the  small  amount  of  blood  obtained  and  the  chances  of  con- 
tamination, especially  from  the  skin.  If  properly  performed,  a  venous 
puncture  is  harmless  and  gives  the  patient  but  little  discomfort. 

Fig.  251. — Apparatus  for  collecting  blood  for  bacteriological  examination. 

Equipment. — A  glass  syringe  with  a  capacity  of  2  1/2  drams 
(about  10  c.c),  a  moderately  large  needle  with  a  sharp  point,  broth 
and  agar-agar  culture  tube,  and  a  bandage  (Fig.  251)  are  necessary. 

Site  of  Puncture. — The  median  cephalic  or  median  basilic  vein  is 
usually  chosen  (see  Fig.  114),  but,  if  these  are  not  available,  the  inter- 
nal saphenous  vein  in  the  leg  or  any  of  the  smaller  veins  about  the 
wrist  may  be  made  use  of. 

Asepsis. — The  skin  at  the  site  of  puncture  is  painted  with  iodin, 
the  hands  of  the  operator  are  as  carefully  sterilized  as  for  any 
operation,  and  the  instruments  are  boiled. 


Anesthesia. — In  ordinary  cases  anethesia  is  unnecessary.  If  it 
is  necessary  to  expose  the  vein  by  an  incision,  as  in  the  case  of  an 
individual  with  much  fat  or  whose  tissues  are  edematous,  infiltration 
with  a  0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  novocain 
solution  is  employed. 

Technic. — A  bandage  is  wound  about  the  arm  between  the  seat  of 
puncture  and  the  heart  with  sufficient  tension  to  produce  a  slight 
venous  stasis  and  cause  the  veins  to  stand  out  prominently,  but  with 
not  enough  compression  to  cut  off  the  arterial  flow.  By  gently  forc- 
ing the  blood  along  toward  the  seat  of  constriction  by  means  of  the 
forefinger  or  thumb,  the  vein  may  be  made  to  stand  out  more  promi- 
nently. In  stout  persons,  however,  it  may  be  necessary  to  expose 
the  vein  by  an  incision. 

The  needle  with  the  syringe  attached  is  then  passed  obliquely 

Fig.  252. — Showing  the  method  of  making  a  venous  puncture. 

through  the  skin  into  the  vein  (Fig.  252),  and  the  blood  is  gently 
sucked  into  the  syringe  by  slowly  withdrawing  the  piston.  If  too 
great  an  amount  of  suction  is  exerted  the  wall  of  the  vein  will  be 
forcibly  collapsed  and  will  act  as  a  valve  against  the  further  with- 
drawal of  blood.  About  i  1/4  drams  (5  c.c.)  of  blood  may  be  taken 
from  a  child,  and  about  2  1/2  drams  (10  c.c.)  from  an  adult.  The 
needle  is  then  withdrawn,  the  constriction  being  first  removed  from 
the  arm  to  avoid  subcutaneous  hemorrhage  from  the  punctured  vein. 
Moderate  pressure  should  be  made  over  the  site  of  puncture  by  a 
piece  of  gauze  held  in  place  by  the  patient  or  by  an  assistant  while 
the  culture  tubes  are  being  inoculated.  This  inoculation  should  be 
done  immediately  and  before  the  blood  has  time  to  clot  in  the 

During  the  inoculation  of  the  tubes  the  greatest  care  should  be 



taken  to  avoid  contamination;  the  needle  is  removed  from  the  syringe' 
as  it  is  very  apt  to  be  contaminated  with  staphylococci  from  the 
skin,  no  matter  how  carefully  the  sterilization  may  have  been  carried 
out,  and  the  inoculation  is  made  through  the  sterile  end  of  the 
syringe.  In  doing  this,  the  same  technic  described  on  page  236  should 
be  followed.  Inoculations  are  usually  made  with  i6Tn,  (i  c.c.)  of 
blood  into  definite  quantities  of  media.  At  the  completion  of  the 
operation  the  seat  of  puncture  is  sealed  with  collodion. 


Sputum  should  be  collected  in  absolutely  clean  wide-mouth 
ounce  (30  c.c.)  glass  bottles,  provided  with  a  water-tight  cork 
(Fig.  253),  so  that  there  can  be  no  leakage  during  transportation. 
Suitable  bottles  may  be  obtained  from  any  laboratory 
or  from  most  drug  stores.  The  specimen  should  be 
obtained  from  the  sputum  coughed  up  early  in  the 
morning  before  any  food  has  been  taken,  and  it  should 
be  seen  that  the  material  is  coughed  up  from  the  lungs 
and  that  it  is  not  simply  an  accumulation  from  the 
mouth  and  pharynx.  As  an  added  precaution  against 
contamination  from  particles  of  food,  tobacco,  vomitus, 
etc.,  the  mouth  and  pharynx  should  first  be  thoroughly 
rinsed  out.  When  there  is  not  sufficient  sputum  from 
one  collection,  the  whole  amount  for  the  day,  or  for 
twenty-four  hours,  should  be  preserved.  The  specimen 
thus  collected  should  be  sent  to  the  laboratory  promptly,  that  it 
may  be  examined  in  as  fresh  a  condition  as  possible. 

In  the  case  of  infants  and  young  children  it  may  be  next  to  im- 
possible to  obtain  sputum  in  the  ordinary  way.  A  method  sometimes 
employed  is  to  pass  a  stomach  tube  into  the  esophagus  and  then 
examine  the  mucus  found  adhering  to  the  tube  upon  its  withdrawal. 
Holt  advises  {Archives  of  Internal  Medicine,  May  15,  19 10)  the  follow- 
ing method:  The  child  is  made  to  cough  by  irritating  the  pharynx 
with  a  bit  of  gauze  or  cotton  held  in  the  jaws  of  an  artery  clamp,  and 
any  secretion  which  is  brought  into  view  is  then  secured  on  this  swab. 

Fig.  253.— 
vSputum  bottle 


When  a  simple  chemical  examination  of  urine  is  called  for,  it  is 
only  necessary  to  collect  the  specimen  in  some  perfectly  clean  re- 
ceptacle, the  first  portion  as  it  comes  from  the  meatus  being  received 



in  another  vessel  and  then  rejected;  but  if  a  culture  is  to  be  made,  the 
urine  must  be  obtained  by  catheter  under  rigid  asepsis.  The  catheter 
must  be  boiled  and  the  hands  of  the  operator  must  be  sterilized  as  for 
any  operation.  The  meatus  and  surrounding  parts  are  then  washed 
with  an  antiseptic  solution,  and  the  catheter  is  gently  inserted  into 
the  bladder  without  touching  the  adjacent  parts  (see  also  page  687). 
The  first  portion  of  the  urine  is  to  be  discarded,  and  then  from  i  1/4 
to  2  1/2  drams  (about  5  to  10  c.c.)  are  collected  in  a  sterile  test-tube, 
which  is  immediately  plugged. 

When  it  is  desired  to  obtain  a  separate  specimen  from  each  kidney, 
the  ureters  may  be  catheterized  (see  page  705)  or  a 
urinary  separator  maybe  employed  (see  page  721). 

To  obtain  a  twenty-four-hour  specimen,  as, 
for  example,  when  it  is  desired  to  determine  the 
total  daily  amount  of  urine  secreted  or  to  esti- 
mate the  total  solids,  it  is  necessary  to  begin  and 
end  with  an  empty  bladder.  The  patient  is  there- 
fore instructed  to  empty  the  bladder  at  a  certain 
hour  and  to  discard  this  specimen.  All  the  urine 
passed  for  the  following  twenty-four  hours,  includ- 
ing that  voided  at  the  end  of  this  period,  is  saved 
in  a  large  clean  bottle.  For  cases  of  incontinence, 
a  retained  catheter  must  be  used  (see  page  689), 
or  else  a  rubber  urinal  devised  for  such  cases  may 
be  employed. 

When  considerable  time  must  elapse  before  a 
specimen  can  be  examined,  some  preservative, 
such  as  boric  acid  in  the  proportion  of  i  grain 
(0.065  gm.)  to  each  ounce  (30  c.c),  formalin  in  the 
proportion  of  i  drop  to  each  4  ounces  (120  c.c),  or  a  few  drops  of 
chloroform  to  each  4  ounces  (120  c.c.)  may  be  added  to  the  speci- 
men. If  culutres  or  inoculations  are  to  be  made,  any  preservative 
should  be  avoided. 

In  the  case  of  infants  there  are  several  methods  for  collecting 
urine.  With  male  infants,  for  an  ordinary  examination,  the  specimen 
may  be  collected  by  means  of  a  condom  which  is  secured  to  the  body 
by  adhesive  plaster,  and  into  which  the  penis  and  scrotum  are  passed ; 
or  a  bottle  may  be  employed,  in  the  neck  of  which  the  penis  is  placed. 
Chapin  has  devised  a  urine  collector  (Fig.  254)  that  may  be  employed 
for  both  males  and  females.  A  method  sometimes  employed  with 
females  is  to  place  absorbent  cotton  over  the  vulva,  and,  after  the 

Fig.  254.-Chapin.'s 
urine  collector. 


child  has  saturated  the  cotton,  to  express  the  urine  into  a  bottle;  or 
the  child  may  simply  be  placed  upon  a  rubber  sheet  from  which  the 
urine  is  collected  as  often  as  it  is  voided.  If  it  is  necessary  to  obtain 
an  uncontaminated  specimen,  catheterizfation  must  be  resorted  to, 
employing  a  small  catheter  (9  to  ii  French). 


For  a  microscopical  examination  of  the  stomach  contents  a  test 
meal  is  not  necessary,  the  vomitus  or  a  portion  removed  by  the 
stomach  tube  (see  page  476)  being  all  that  is  required.  The  specimen 
should  be  received  in  a  clean  glass  receptacle. 

For  a  complete  chemical  examination  and  to  test  the  condition  of 
the  stomach,  the  gastric  contents  an  hour  after  a  test-meal  will  be 
required  (see  page  475). 


Ordinarily  a  small  amount  should  be  received  in  a  sterilized 
wide-mouth  glass  jar  and  the  examination  made  as  soon  as  possible. 

When  examining  for  the  ameba,  it  becomes  necessary  to  collect 
the  stools  in  a  clean  warm  receptacle  and  to  make  the  examination 
immediately  upon  a  warmed  slide,  or  else  to  provide  some  means  for 
keeping  the  specimen  warm  until  the  examination  can  be  conveniently 



The  excision  of  pieces  of  tissue  for  microscopical  examination 
may  be  required  in  cases  where  it  seems  probable  that  a  tumor  is 
malignant  but  where  the  clinical  signs  and  symptoms  are  not  pro- 
nounced enough  to  make  a  positive  diagnosis.  The  information  thus 
obtained  is  especially  valuable  in  growths  of  recent  development,  as 
in  these  the  evidence  of  malignancy  is  often  not  apparent  from  a 
gross  examination. 

Instruments.^ — In  ordinary  cases  there  will  be  required :  a  scalpel, 
scissors,  a  cutaneous  punch,  artery  clamps,  plain  thumb  forceps 
mouse-toothed  forceps,  small  sharp  retractors,  a  needle  holder.  No.  2 
catgut  sutures,  curved  needles  with  cutting-edges,  and  a  wide-mouth 
clean  bottle  provided  with  a  water-tight  cork  and  containing  a  4 
per  cent,  aqueous  solution  of  formalin  (Fig.  255). 

For  regions  which  are  not  readily  accessible,  as,  for  example,  the 


Fig.  255. — Instruments  for  excising  a  fragment  of  solid  tissue  for  examination. 
I,  Scalpel;  2,  curved  sharp-pointed  scissors;  3,  skin  punch;  4,  thumb  forceps;  5, 
artery  clamps;  6,  retractors;  7,  needle  holder;  8,  No.  2  catgut;  9,  curved  cutting- 
edge  needles;  10,  specimen  bottle. 

Fig.  256. — Excision  of  a  piece  of  tissue  from  the  cervix.      (Ashton.) 



female  genitals,  volsellum  forceps  and  suitable  specula  are  necessary. 

For  collecting  material  from  the  interior  of  the  uterus,  curettage 
instruments,  etc.,  will  be  required  (see  page  808). 

Anesthesia. — As  a  rule,  local  anesthesia  by  infiltration  with   a 

Fig.  257. — Removal  of  a  fragment  of  a  superficial  growth  with  a  skin  punch. 

0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  solution  of  novocain 
in  normal  salt  solution  is  sufficient.  For  skin  tumors,  freezing  with 
ethyl  chlorid  usually  suffices. 


Fig.  258. — Removal  of  a  fragment  of  a  superficial  growth  with  a  skin  punch- 
Second  step,  cutting  loose  the  base  of  the  section. 

Asepsis. — The  instruments  are  boiled,  the  hands  of  the  operator 
are  sterilized,  and  the  site  of  operation  is  cleaned  as  for  any  operation. 

Technic. — The  fine  of  proposed  incision  is  first  anesthetized. 
Then,  with  the  tissues  well  retracted  so  as  to  expose  the  growth,  a 


wedge-shaped  piece  of  tissue  is  removed  by  means  of  a  scalpel  from 
the  portion  of  the  growth  where  the  pathological  changes  are  most 
marked  or  the  tumor  is  nodular  (Fig.  256).  The  tissue  is  then  trans- 
ferred to  the  bottle  containing  the  4  per  cent,  formalin  solution,  and  a 
proper  label  is  applied.  Any  hemorrhage  is  then  controlled,  the 
incision  is  closed,  and  a  sterile  dressing  is  finally  applied. 

A  fragment  of  a  very  superficial  tumor  or  of  a  skin  growth  may  be 
removed  by  means  of  a  punch  if  desired.  The  skin  is  frozen  with 
ethyl  chlorid,  and  by  a  rotary  motion  the  punch  is  made  to  cut  out  a 
circular  piece  of  tissue  (Fig.  257),  The  punch  is  then  removed  and 
the  circular  core  is  seized  in  thumb  forceps  and  is  freed  from  its 
base  by  cutting  with  a  pair  of  curved  scissors  (Fig.  258).  The  punch 
may  be  employed  in  the  same  way,  if  desired,  for  removal  of  deeper 
seated  growths  after  first  exposing  the  tumor  by  an  incision. 

When  tissue  is  removed  by  curettage  for  examination,  the  uterus 
should  be  scraped  systematically,  and,  as  soon  as  collected,  the  frag- 
ments thus  obtained  should  be  placed  in  a  bottle  containing  the 
preserving  fluid.  The  bottle  is  then  carefully  labeled.  Care  should 
be  taken  to  avoid  rough  handling  of  the  tissues  and  to  preserve  for 
examination  all  the  fragments  removed.  For  the  technic  of  curettage 
see  page  809. 



An  exploratory  puncture  consists  in  the  introduction  of  a  hollow 
needle  attached  to  an  aspirating  syringe  into  a  diseased  region,  and  a 
subsequent  aspiration.  This  comparatively  simple  operation  may 
be  performed  for  the  purpose  of  determining  the  presence  or  absence 
of  fluid  in  any  particular  area,  or  to  obtain  a  specimen  of  fluid  for 
the  purpose  of  determining  its  character  by  subsequent  examination. 
In  addition,  exploratory  punctures  are  made  prior  to  therapeutic 
punctures  to  determine  the  exact  location  of  the  fluid  to  be  evacuated. 
In  deeply  seated  processes,  as  suppuration  and  fluctuating  tumors, 
inaccessible  to  other  means  of  diagnosis,  this  method  of  exploration 
often  gives  most  valuable  information.  The  liver,  the  lungs,  the 
pleural  and  pericardial  cavities,  the  spinal  canal,  and  other  organs 
and  regions  difficult  of  access  may  thus  be  tapped  and  explored  with 
comparative  safety. 

Whenever  fluid  is  detected  a  quantity  suflScient  for  examination 
should  be  withdrawn.  Frequently  by  a  gross  examination  of  the 
fluid  sufficient  information  may  be  obtained  as  to  its  character. 
With  the  naked  eye.  one  can  often  make  a  diagnosis  between  a  serous, 
bloody,  or  purulent  fluid,  by  carefully  noting  the  color,  clearness,  and 
consistency  of  the  material  withdrawn.  \'aluable  information  can 
likewise  be  obtained  from  the  odor. 

For  more  definite  and  exact  information,  a  chemical,  microscopi- 
cal, and  bacteriological  examination  will  be  necessary.  In  prepara- 
tion for  such  an  examination  a  few  drops  of  the  Hquid  should  be 
injected  into  culture  tubes,  and  the  remainder  placed  in  a  sterilized 
test-tube,  previously  provided,  and  kept  in  readiness  for  this  purpose. 
At  times  the  aspirated  fluid  may  be  so  thick  that  only  a  few  flakes  or 
floccules  of  purulent  matter  can  be  obtained.  Such  material,  or  any 
fragments  of  tissue  adhering  to  the  needle  point  should  be  carefully 
transferred  to  a  glass  slide  for  later  microscopical  examination. 
Even  specimens  from  solid  growths  large  enough  for  microscopical 
examination  may  at  times  be  obtained  by  rotating  the  needle  and 
moving  it  back  and  forth  sufficiently  to  detach  a  small  fragment, 
which  may  then  be  secured  by  producing  a  strong  vacuum  in  the 
syringe  and  very  carefully  withdrawing  the  needle. 


The  laboratory  examination  of  the  fluid,  the  technic  of  which  may 
be  found  fully  described  in  manuals  on  clinical  laboratory  methods, 
should  be  made  along  the  following  lines  and  with  reference  to  the 
special  points  mentioned. 

1.  Physical  Characteristics. — The  color,  odor,  clearness,  consist- 
ency, reaction,  coagulability  and  specific  gravity  of  the  fluid,  and 
the  character  of  the  sediment  should  be  noted. 

2.  Chemical  examination  should  include  tests  for  albumin,  serum 
globulin,  sugar,  bile,  urea,  blood,  pus,  etc, 

3.  Microscopical  examination  is  made  for  the  purpose  of  detecting 
the  presence  of  blood-corpuscles,  epithelial  cells,  hematoidin  and 
cholesterin  crystals,  specific  tumor  cells  or  fragments,  necrotic  tissue, 
ameba,  hydatid  booklets,  ray  fungi,  etc. 

4.  Bacteriological  Examination. — Smear  preparations  are  made 
and  examined  for  pathogenic  bacteria,  while  organisms  susceptible 
of  culture  are  inoculated  upon  suitable  media  and  later  examined 
microscopically.  Thus  organisms  may  be  identified  which  are  not 
readily  detected  by  direct  examination. 

5.  Cytodiagnosis. — By  this  is  understood  the  determination  of 
the  cause  of  an  effusion  from  the  relative  number  and  the  character 
of  its  cellular  constituents. 


This  is  a  safe  and  simple  operation  employed  to  confirm  the 
diagnosis  of  a  pleural  eft'usion  or  to  ascertain  the  nature  of  the  fluid. 
The  danger  of  injuring  the  lung  and  producing  a  pneumothorax  need 
not  be  considered  if  reasonable  care  be  observed  in  performing  the 

Apparatus. — Aspirating  needles  and  a  syringe  of  appropriate  size 
should  be  provided.  It  Avill  be  found  convenient  to  have  an  assort- 
ment of  needles  of  difl'erent  lengths  and  diameters.  They  should 
measure  in  length  2  1/2  inches  (6.5  cm.),  3  inches  (7.5  cm.),  31/2 
inches  (9  cm.),  and  4  inches  (10  cm.);  and  in  diameter  1/50  inch  (0.5 
mm.),  1/25  inch  (i  mm.),  1/18  inch  fi.5  mm.),  and  1/12  inch  (2 
mm,).  For  ordinary  use  the  needle  should  be  at  least  3  inches  (7.5 
cm.)  long  and  about  1/25  inch  (i  mm.)  in  diameter,  so  that  it  will 
readily  giv^e  passage  to  fluids  of  heavy  consistency. 

It  is  preferable  to  have  a  syringe  with  a  capacity  of  from  i  to  2 
drams  (4  to  8  c.c),  though  an  ordinary  hypodermic  syringe  may  be 
employed  if  the  large  needles  are  made  to  fit.     The  syringe  should  be 



capable  of  exerting  a  strong  suction,  and  the  joint  between  it  and  the 
needle  should  be  absolutely  air-tight.  The  best  form  of  syringe  con- 
sists of  a  solid  glass  barrel  and  a  tight-fitting  piston  provided  with  an 
asbestos  or  rubber  packing  (Fig.  259).  Such  a  syringe  is  simple  in 
mechanism,  easy  to  clean,  and  can  be  readily  sterilized  by  boiling. 
If  confirmation  of  the  diagnosis  of  fluid  is  to  be  immediately  followed 

Fig.  259. — Aspirating  syringe  and  needles. 

by  its  evacuation,  the  aspirating  apparatus  of  Potain  or  Dieulafoy 
(see  page  286)  may  be  used  for  the  exploration,  thus  sparing  the 
patient  a  subsequent  operation. 

In  addition  there  should  be  provided  a  scalpel  and  a  cocain 
syringe  or  tube  of  ethyl  chlorid  for  anesthetizing  the  point  of  puncture. 

Before  making  a  puncture  the  syringe  should  always  be  tested 


Pig,  260. — Apparatus  for  making  smears  and  cultures  from  fluids  removed  by 
exploratory  puncture,      i,  Glass  slides;  2,  sterile  test-tube;  3,  culture  tubes. 

by  withdrawing  the  piston  with  the  finger  held  over  the  end,  to  see  if 
it  will  exert  proper  suction.  The  syringe  should  likewise  be  tested 
with  the  needle  fitted  in  place.  After  use,  the  syringe  should  be 
taken  apart,  and  both  it  and  the  needle  should  be  thoroughly  cleansed. 
To  guard  against  rusting,  the  lumen  of  the  needle  should  be  cleansed 
with  alcohol  and  ether,  and  a  wire  of  suitable  size  inserted. 



In  cases  where  a  complete  chemical,  microscopical,  and  bac- 
teriological examination  is  desired,  sterilized  test-tabes  for  collecting 
and  transporting  the  material  aspirated,  glass  slides,  and  agar-agar 
culture  tubes  (Fig.  260)  should  be  at  hand. 

Location  of  the  Puncture.— No  fixed  rule  can  be  laid  down,  the 
point  chosen  for  the  puncture  depending  upon  the  physical  examina- 
tion. The  needle  should  enter  a  spot  where  there  is  dullness  and  an 
absence  of  respiratory  sounds,  voice,  and  fremitus,  and,  at  the  same 
time,  the  point  of  puncture  should  lie  well  below  the  upper  level  of 
the  effusion.     If  it  is  made  too  high,  the  point  of  the  needle  may 


261. — Showing  the  points  for  inserting  the  needle  in  exploratory  puncture  of 
the  pleura.      (Large  dots  represent  points  of  election.) 

lacerate  the  lung;  or,  if  too  low,  injury  to  the  diaphragm,  liver,  or 
spleen  may  result.  As  a  general  thing,  entrance  of  the  needle  in 
the  sixth  interspace  in  the  anterior  axillary  line,  in  the  sixth  or  seventh 
interspace  in  the  midaxillary  Une,  or  the  eighth  interspace  below 
the  angle  of  the  scapula  will  reveal  the  presence  of  fluid  if  such  exist 
(Fig.  261). 

Position  of  the  Patient. — If  too  weak  to  sit  upright,  the  patient 
may  He  semirecumbent  for  a  lateral  puncture,  and  for  a  posterior 
puncture  in  a  lateral  prone  position,  with  the  body  carved  forward 
and  the  arm  of  the  affected  side  elevated  (Fig.  262).  In  uncom- 
pHcated  cases,  an  upright  sitting  posture  should  be  assumed,  with  the 



arm  of  the  affected  side  elevated  for  the  purpose  of  widening  the 
intercostal  spaces  (Fig.  263). 

Asepsis. — The  strictest  regard  to  asepsis  must  be  observed  in  mak- 

FiG.  262. — Lateral  position  for  exploratory  puncture  of  the  pleura. 

Fig.  263. — Exploratory  puncture  of  the  pleura  with  the  patient  sitting  upright. 

ing  any  exploratory  puncture,  otherwise  there  is  great  risk  of  in. 
fection  and  of  converting  a  simple  serous  exudate  into  a  purulent  one. 



The  site  chosen  for  the  puncture  should  be  well  painted  with  tinc- 
ture of  iodin.  The  operator's  hands  should  also  be  thoroughly 
scrubbed,  followed  by  immersion  in  an  antiseptic  solution.  The 
needles,  svringes,  and  other  instruments  employed  are  sterilized 
by  boiling. 

Anesthesia. — ^Local  anesthesia  by  freezing  with  ethyl  chlorid  or 
salt  and  ice.  or  infiltrating  with  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  solution  of  novocain,  will  be  all  that  is  required. 
In  emplopng  cold  as  an  anesthetic,  if  the  patient  is  poorly  nourished 
or  the  skin  is  edematous,  care  should  be  taken  not  to  freeze  the  skin 
too  thoroughly,  on  account  of  the  danger  of  local  necrosis. 

Technic. — To  avoid  injury  to  the  upper  intercostal  artery  the 
needle  is  inserted  near  the  upper  margin  of  the  rib  which  forms  the 

Fig.  264.  Fig.  265. 

Fig.  264. — Showing  the  failure  to  withdraw  flmd  from  the  needle  being  inserted 
too  far.      (xAiter  Gumprecht.) 

Fig.  265. — Showing  the  failure  to  withdraw  fluid  from  the  needle  entering  the 
pleura  at  too  high  a  level.      (After  Gumprecht.) 

lower  boundary  of  the  space  chosen  for  the  puncture.  The  point  of 
puncture  is  anesthetized  and  a  small  nick  is  made  in  the  skin. 
The  thumb  and  forefinger  of  the  left  hand  steady  the  tissues,  while 
the  needle  is  slowly  and  steadily  inserted  upward  and  inward,  until 
its  point  enters  the  pleural  sac.  From  i  to  i  i^  2  inches  (about  2.5 
to  4  cm.)  under  ordinary  conditions,  and  more  in  fat  subjects  or  in 
those  with  very  thick  pleura,  may  be  estimated  as  the  thickness  of 
the  thoracic  wall  through  which  the  needle  will  have  to  pass  before 
entering  the  pleural  cavity.  The  lack  of  resistance  and  the  mobility 
of  the  needle  will  acquaint  one  of  its  entrance  into  a  ca\"ity. 

If  fluid  is  not  immediately  obtained,  the  direction  of  the  needle 
may  be  changed  slightly,  or  it  may  be  entirely  withdrawn  and  inserted 
in  other  locations  before   the  attempt  is   abandoned.     Failure  to 



withdraw  fluid  may  be  due  to  the  needle  entering  the  lung  CFig.  265) 
or  to  the  fluid  being  encapsulated  in  a  space  not  entered  by  the 
aspirating  needle.  Again,  the  point  of  the  needle  may  become  buried 
in  adhesions  or  a  thickened  pleura  (Fig.  266),  or  its  caliber  may  be- 
come blocked  by  coagulated  material.  In  addition  to  determining 
the  presence  of  fluid,  any  unusual  thickness  or  density  of  the  pleura 
may  be  appreciated  by  the  operator  through  the  amount  of  resis- 
tance oft"ered  to  the  entrance  of  the  needle.  Upon  completion  of  the 
aspiration,  the  needle  is  quickly  withdrawn,  and  the  site  of  the 
puncture  is  closed  with  collodion  and  cotton. 

Fig.  266. — Showing  the  faikire  to'  withdraw  fluid -from  the  point  of  the  needle 
becoming  imbedded  in  a  thickened  pleura.      (After  Gumprecht.) 


Previous  to  undertaking  any  operative  procedure  upon  a  pul- 
monary cavity,  such  as  a  tubercular,  bronchiectatic,  echinococcic,  or 
abscess  cavity,  an  exploratory  puncture  will  be  of  great  service,  not 
only  as  an  aid  to  a  physical  examination  in  detecting  such  a  cavity, 
but  likewise  in  determining  its  size  and  exact  location,  and  its 
character  by  an  examination  of  the  fluid  withdrawn. 

There  is  considerable  risk  of  infecting  the  pleura  or  of  producing 
a  cellulitis  if  aspiration  of  a  pulmonary  cavity  without  immediate 
drainage  be  performed,  hence  the  exploratory  puncture  should  only 
be  performed  on  the  operating-table  with  the  patient  ready  to  be 
anesthetized,  and  with  all  preparations  to  incise  and  drain  the  cavity 
completed  beforehand,  in  case  pus  is  obtained. 

Apparatus. — Exploring  needles  and  a  glass  aspirating  syringe,  a 
scalpel,  ethyl  chlorid  or  a  cocain  syringe,  test  tubes,  and  culture 
tubes  will  be  required  (see  page  259). 

Location  of  the  Puncture. — This  will  depend  entirely  upon  the 


approximate  situation  of  the  cavity,  as  determined  by  the  physical 

Asepsis. — The  instruments  should  be  boiled,  the  operator's  hands 
sterilized  as  for  any  operation,  and  the  site  of  puncture  painted  with 

Anesthesia. — Infiltration  of  the  site  of  puncture  with  a  0.2  per 
cent,  solution  of  cocain  or  a  i  per  cent,  novocain  solution,  or  freezing 
by  means  of  ethyl  chlorid  or  salt  and  ice  will  be  sufficient. 

Technic. — A  fair-sized  aspirating  needle,  at  least  4  inches  (10  cm.) 
long,  will  be  required.  The  point  of  puncture  is  anesthetized  and 
the  skin  is  nicked  with  the  point  of  a  scalpel.  Then,  while  the  patient 
holds  the  breath  to  limit  movement  of  the  lungs,  the  needle  is  in- 
serted in  the  direction  of  the  supposed  cavity,  close  to  the  upper 
margin  of  the  rib,  in  the  same  manner  as  already  described  for  ex- 
ploratory puncture  of  the  pleura  (page  263).  As  the  needle  is  slowly 
advanced,  attempts  to  withdraw  fluid  are  made  at  successive  depths. 
The  abscess  may  be  superficial,  and  even  adherent  to  the  chest  wall 
where  it  can  be  easily  reached,  but  more  often  it  will  be  necessary  to 
insert  the  needle  a  distance  of  3  to  4  inches  (7.5  to  10  cm.)  before  the 
cavity  is  entered.  Failing  to  withdraw  pus,  the  needle  should  be 
removed  and  reinserted  at  another  spot.  It  may  even  be  necessary 
to  make  a  number  of  punctures  before  being  successful,  as  the  locali- 
zation of  a  pulmonary  cavity  is  at  times  a  most  difficult  matter. 
When  a  needle  enters  a  cavity,  some  idea  of  its  size  may  be  obtained 
from  the  range  of  motion  of  the  needle  and  from  the  quantity  of 
secretion  withdrawn,  though,  if  there  has  been  considerable  expec- 
toration previous  to  the  puncture,  little  or  no  fluid  will  be  obtained, 
even  though  the  needle  enter  a  cavity. 

When  pus  is  obtained,  the  needle  should  be  left  in  place  as  a 
guide  for  the  incision  and  drainage,  and,  while  the  patient  is  being 
anesthetized,  great  care  should  be  taken  to  see  that  the  needle  is  not 


An  exploratory  puncture  may  be  required  as  a  means  of  making  a 
positive  diagnosis  of  the  presence  of  fluid  within  the  pericardium  or 
for  the  purpose  of  choosing  a  route  through  which  such  fluid  may  be 
reached  and  evacuated.  Puncture  of  the  pericardium  should  not  be 
undertaken  lightly,  and  the  dangers  of  injuring  the  internal  mammary 
vessels  or  pleura,  or  of  puncturing  the  thin-walled  auricles  of  the 



heart,  should  impress  upon  the  operator  the  necessity  of  extreme  care 
when  performing  this  operation. 

Apparatus. — A  fine  exploring  needle  and  a  glass  aspirating  syringe, 
a  scalpel,  ethyl  chlorid  or  a  cocain  syringe,  test  tubes,  and  culture 
tubes  will  be  required  (see  page  259). 

Location  of  the  Puncture. — To  eliminate  as  far  as  possible  the 
dangers  of  the  operation,  special  sites  for  puncture  have  been  rec- 
ommended, as  follows:  (i)  In  the  fourth  or  fifth  interspace,  either 
close  to  the  left  sternal  margin  or  i  inch  (2.5  cm.)  to  the  left  of  it. 
Either  of  these  points  will  avoid  the  internal  mammary  artery  and 

Fig.  267. — -Points  for  puncturing  the  pericardium.  The  dotted  line  indicates 
a  distended  pericardial  sac.  The  course  of  the  internal  mammarj'^  vessels  is  also 

veins  which  run  vertically  downward  1/2  inch  (i  cm.)  from  the  ster- 
nal margin.  (2)  In  the  fifth  intercostal  space,  close  to  the  right  of 
the  sternum.  It  is  claimed  that  from  this  point  it  is  impossible  to 
injure  the  heart,  but  this  avenue  of  approach  is  only  suitable  when  the 
amount  of  fluid  is  large.  (3)  Inserting  the  needle  directly  upward 
and  backward  close  to  the  costal  margin  in  the  space  between  the 
ensiform  cartilage  and  the  seventh  costal  cartilage  on  the  left  side. 
(4)  When  it  is  possible  to  outline  accurately  the  shape  of  the  peri- 
cardium and  locate  the  position  of  the  apex  beat  by  means  of  pulsa- 
tion or   friction  rubs,    the   method   recommended   by    Curschman, 


Romberg,  Kussmaul,  and  others,  may  be  employed.  The  puncture 
is  made  in  the  hfth  or  sixth  left  interspace  outside  the  nipple  line 
between  the  apex  beat  and  the  outer  limit  of  dullness  (Fig.  267). 

The  selection  of  one  of  these  sites  over  the  others  will  be  made 
according  to  the  degree  of  distention  of  the  pericardium  and  its 
shape,  which  is  determined  by  outlining  the  area  of  dullness. 

Preparation  of  the  Patient. — If  the  patient  be  a  male,  the  chest 
should  be  shaved,  and,  in  any  case,  the  skin  must  be  steriHzed  thor- 
oughly before  making  the  puncture. 

Position  of  the  Patient. — The  operation  may  be  performed  with 
the  patient  semirecumbent  or  in  the  upright  sitting  posture. 

Fig.  268.- — Showing  the  method  of  inserting  the  needle  in  an  exploratory  puncture 

of  the  pericardium. 

Technic. — As  already  emphasized,  all  the  aseptic  precautions  enu- 
merated under  exploratory  punctures  (page  262)  should  be  carefully 
carried  out.  The  area  of  dullness  is  accurately  mapped  out  and  the 
point  for  puncture  thereby  determined  upon.  This  point  is  anes- 
thetized and  a  small  nick  is  made  in  the  skin.  The  thumb  of  the  left 
hand  is  placed  as  a  guide  upon  the  lower  rib  bounding  the  intercostal 
space  selected,  and  the  needle  point  is  inserted  just  above  the  margin 
of  the  rib  so  as  to  avoid  the  upper  intercostal  artery  (Fig.  268).  The 
needle  should  be  introduced  slowly  and  with  great  care  almost  in  the 
sagittal  plane  and  directed  slightly  toward  the  median  line.  En- 
trance into  the  pericardial  sac  is  suspected  when  resistance  to  the 
progress  of  the  needle  is  no  longer  encountered,  or  when  the  heart  is 
felt  striking  against  the  needle  point.     The  needle  should  not  be 


inserted  a  greater  distance  than  i  inch  (2.5  cm.),  and,  if  fluid  is  not 
reached  at  this  depth  from  one  location  the  other  points  of  entrance 
above  mentioned  may  be  employed.  Should  the  fluid  obtained  be 
purulent  in  character,  prompt  incision  and  drainage  is  indicated. 

When  the  purpose  of  the  puncture  is  accomplished,  the  needle  is 
slowly  withdrawn,  and  the  point  of  puncture  is  sealed  with  collodion 
and  cotton. 


Aspiration  of  small  quantities  of  peritoneal  fluid  and  examination 
of  the  specimen  obtained  may  be  required  to  determine  the  type  of  an 
effusion  into  the  peritoneal  cavity — whether  it  be  serous,  inflam- 
matory, hemorrhagic,  or  chylous.  Puncture  of  solid  or  fluctuating 
masses  within  the  abdomen  may  likewise  be  performed  as  a  diagnostic 
measure,  but  the  dangers  of  producing  serious  complications  through 
puncture  of  the  intestine  or  other  organs,  or  from  leakage  of  fluid, 
especiaUy  if  it  be  purulent,  into  the  peritoneal  cavity  stamps  it  as  an 
unsafe  method  except  in  those  cases  where  the  tumor  is  in  close  rela- 
tion to  the  abdominal  wall.  When  the  presence  of  pus  is  suspected, 
it  is  not  wise  to  perform  an  exploratory  puncture  unless  everything 
is  in  readiness  for  an  immediate  operation.  The  comparative  safety 
of  an  exploratory  laparotomy  and  the  fact  that  much  more  valu- 
able information  can  be  thus  obtained  render  this  the  operation  of 

Apparatus. — A  long  exploring  needle,  a  glass  aspirating  syringe, 
a  scalpel,  a  cocaine  syringe,  test-tubes,  etc.,  should  be  provided  (see 
page  259). 

Location  of  the  Puncture. — For  puncture  of  the  peritoneal  cavity, 
a  point  midway  between  the  umbilicus  and  the  pubes  in  the  median 
line  or  a  point  at  the  junction  of  the  outer  and  middle  thirds  of  a  line 
between  the  anterior  superior  spine  and  the  navel  should  be  chosen 
for  the  insertion  of  the  needle.  Both  these  sites  will  escape  the 
deep  epigastric  artery  (Fig.  269). 

Position  of  the  Patient. — The  patient  either  sits  upright,  in  order 
to  allow  the  gravitation  of  the  fluid  to  the  lowest  level,  or  he  may  be 
propped  up  in  a  semireclining  position.  For  a  lateral  puncture  the 
patient  should  lie  upon  his  side. 

Preparation  of  the  Patient. — The  site  for  puncture  should  be 
shaved  and  properly  sterilized.  The  bladder  should  always  be  emptied 
inwiediately  before  tJie  operation. 



Anesthesia. — Infiltration  cocain  or  novocain  anesthesia  or  freez- 
ing with  ethyl  chlorid  will  suffice. 

Technic. — The  point  chosen  for  the  puncture  is  anesthetized,  and 
a  small  nick  is  made  in  the  skin.  The  needle  is  inserted  directly  back- 
ward until  the  resistance  of  the  abdominal  wall  is  no  longer  felt  and 
the  point  of  the  needle  moves  freely  within  the  abdominal  cavity. 
Sufficient  fluid  is  withdrawn  for  examination,  and,  after  removal  of 
the  needle,  the  site  of  entrance  is  closed  with  a  thin  layer  of  collodion 
and  cotton. 

Fig.  269. — Points  for  puncture  of  the  peritoneal  cavity. 


Exploration  of  the  liver  by  means  of  an  aspirating  needle  may  be 
required  for  the  purpose  of  making  a  positive  diagnosis  in  cases  of 
suspected  amebic  or  pyogenic  abscess,  or  hydatid  cyst.  Exploratory 
puncture  should  not  be  performed,  however,  unless  the  preparations 
for  an  immediate  operation,  if  such  be  necessary,  are  completed 
beforehand,  for  no  matter  how  small  the  puncture  may  be,  leakage  of 
fluid  is  liable  to  occur  and  cause  serious  damage. 

Apparatus. — An  exploring  syringe,  needles,  a  scalpel,  test-tubes, 
etc.,  such  as  is  required  for  any  exploratory  puncture  (seepage  259), 
should  be  provided. 



Location  of  the  Puncture. — This  will  depend  -upon  the  symptoms 
and  physical  signs  in  each  individual  case.  If  at  any  one  point  there 
be  localized  pain,  tenderness  on  palpation,  peritoneal  crepitation,  or 
distinct  bulging,  such  spot  should  be  chosen  for  the  puncture.  In 
the  absence  of  signs  pointing  to  localization,  the  fact  that  most  liver 
abscesses  are  situated  in  the  upper  posterior  portion  of  the  right  lobe 
should  be  borne  in  mind  and  the  puncture  made  accordingly,  the 
needle  being  inserted  in  the  midaxillary  line  on  the  right  side  through 
the  ninth,  tenth,  or  eleventh  interspace,  or  below  the  angle  of  the 
scapula  through  the  tenth  interspace  (Fig.  270).     Puncture  may  also 

Fig.  270. — Points  for  puncture  of  the  liver. 

be  made  anteriorly  directly  into  the  area  of  liver  dullness  below  the 
line  of  the  pleura. 

Asepsis. — The  operation  is  performed  under  all  aseptic  precau- 
tions (see  page  262). 

Anesthesia. — The  puncture  may  be  made  under  local  anesthesia, 
but,  if  it  is  likely  that  a  number  of  punctures  will  be  necessary  and  an 
operation  is  to  be  performed,  it  is  better  to  give  a  general  anesthetic 
at  the  start. 

Technic— After  making  a  small  nick  in  the  skin  with  a  scalpel  at 
the  site  chosen  for  the  puncture,  the  needle  is  slowly  introduced 
inward  and  slightly  upward  to  its  full  extent,  and  suction  is  attempted. 


If  fluid  i5  not  obtained,  the  needle  is  slowly  withdrawn,  a  vacuum 
being  maintained  in  the  syringe  in  the  meantime,  so  as  to  withdraw 
pus  in  case  the  point  of  the  needle  has  previously  passed  through  a 
ca\-ity  into  healthy  tissue.  Near  the  surface  of  the  liver  the  direc- 
tion of  the  needle  is  altered,  and  it  is  inserted  again  in  a  different 
plane.  In  this  manner  a  large  area  of  the  HA'er  may  be  explored  in 
aU  directions  from  one  external  puncture,  provided  care  is  exercised 
not  to  injure  the  pleura  and  lung  above,  or  the  gall-bladder  and 
intestines  below.  The  needle  should  not  be  inserted  to  a  greater 
depth  than  3  3,  4  (9.5  cm.)  inches  from  the  surface  of  the  body  for 
fear  of  injuring  the  inferior  vena  cava.  To  avoid  lacerating  the 
liver,  the  exploring  needle  must  be  allowed  to  move  freely  with  the 
liver  as  it  rises  or  descends  during  respiration.  If  fluid  is  not  immedi- 
ately found,  a  number  of  punctures  should  be  made  before  the  opera- 
tion is  abandoned.  Failure  to  draw  pus  into  the  s}Tinge  does  not 
necessarily  signify  absence  of  an  abscess,  for  at  times  the  material 
forming  the  abscess  is  so  thick  that  it  wiU  not  pass  into  the  needle, 
and  only  a  drop  or  two  of  pus  will  be  discovered  on  close  examination, 
clinging  to  the  needle  point. 

Having  located  an  abscess,  the  needle  should  be  left  in  situ  as  a 
guide,  for  it  is  not  an  uncommon  experience,  when  pus  is  discovered 
by  aspiration  and  the  needle  removed,  to  fail  to  locate  the  abscess  at  a 
subsequent  operation. 


As  a  diagnostic  measure,  puncture  of  the  spleen  may  be  performed 
\\-ithout  danger  if  the  organ  is  hard,  as  is  found  in  chronic  malaria, 
but  in  infectious  diseases  with  a  large,  soft,  and  friable  spleen  it  is 
an  unjustifiable  procedure.  Laceration  of  the  capsule  followed  by 
hemorrhage,  suppuration  in  the  spleen,  and  peritonitis  have  been 
known  to  result.  Likewise  puncture  of  the  spleen  in  suspected  cases 
of  t}'phoid  fever  is  no  longer  warranted,  since  we  have  other  methods 
of  diagnosis,  such  as  Widal's  test,  which  are  both  safe  and  adequate. 
When  fluctuation  has  been  demonstrated,  as  in  splenic  abscess  or 
hydatid  disease,  examination  of  the  fluid  obtained  by  aspiration  may 
give  conclusive  information;  but  here  again,  as  in  exploratory  punc- 
tures of  the  liver  or  lungs,  preparations  for  incision  and  drainage,  in 
case  such  should  be  necessary,  should  be  completed  before  the 
puncture  is  made. 

Apparatus. — Exploring  needles,  an  aspirating  syringe,  and  other 



instruments  necessary  for  any  exploratory  puncture  (see  page  259) 
should  be  provided. 

Location  of  Puncture. — The  spleen  can  be  reached  by  insert- 
ing the  needle  through  the  tenth  intercostal  space  in  the  midaxillary 
line  on  the  left  side  (Fig.  271),  If  the  organ  is  markedly  enlarged, 
some  point  below  the  left  costal  margin,  determined  by  percussion  of 
the  spleen,  may  be  chosen. 

Position  of  the  Patient. — The  patient  may  assume  either  the 
sitting  posture  with  the  left  arm  elevated  and  the  hand  on  the  oppo- 

FlG.  271. — Point  for  puncturing  the  spleen. 

site  shoulder,  or  the  recumbent  position,  depending  upon  which 
gives  the  most  ready  access  to  the  region  of  operation. 

Asepsis. — The  same  as  for  any  exploratory  puncture  (see  page 

Anesthesia. — ^Local  infiltration  anesthesia  or  freezing  will  suffice. 

Technic. — A  fine  and  fairly  long  aspirating  needle  should  be 
employed.  The  patient  is  instructed  to  hold  his  breath,  to  lessen  the 
danger  of  lacerating  the  organ,  and  the  operator  makes  a  small  nick 
in  the  skin,  quickly  inserts  the  needle  at  the  chosen  site,  and  makes 
the  aspiration  with  as  httle  delay  as  possible.  The  needle  is  then 
withdrawn,  and  the  site  of  puncture  is  closed  with  a  thin  covering  of 
collodion  and  cotton. 




Exploratory  aspiration  may  be  employed  to  detect  collections  of 
pus  or  other  fluids  in  the  region  of  the  kidney.  An  exploratory 
incision,  however,  and  subsequent  aspiration  after  exposure  of  the 
mass  is  a  far  more  satisfactory  method  of  diagnosis. 

Apparatus. — An  aspirating  syringe,  exploring  needles,  and  other 
apparatus  necessary  for  making  an  exploratory  puncture  (see  page 
259)  should  be  at  hand. 

Location  of  the  Puncture. — The  needle  should  be  introduced  at  a 
point  about  2  1/2  inches  (6  cm.)  from  the  median  line,  to  avoid  the 

Fig.  272. — Showing  the  relations  of  the  kidneys  from  behind. 

erector  spinas  muscles,  and  a  httle  below  the  last  rib  on  the  left  side, 
and,  on  the  right  side,  between  the  last  rib  and  the  crest  of  the  ilium. 

Position  of  Patient. — The  patient  may  sit  up,  with  the  back  bent 
forward,  or  he  may  lie  partly  upon  the  unaffected  side  and  partly  upon 
the  abdomen,  with  the  body  bent  forward  in  a  curve. 

Asepsis. — The  usual  aseptic  precautions  are  to  be  observed  (see 
page  262). 

Anesthesia. — ^Local  infiltration  anesthesia  or  freezing  will  sufhce. 

Technic. — A  long  fine  needle  should  be  employed.  After  nicking 
the  skin  with  a  scalpel  at  the  site  chosen  for  the  puncture,  the  needle 


is  slowly  introduced  forward  and  slightly  inward  toward  the  median 
line,  frequent  tests  at  aspiration  being  made  as  the  needle  is  advanced. 
When  fluid  is  discovered,  a  sufficient  quantity  for  diagnosis  is  with- 
drawn, and  the  site  of  puncture  is  sealed  with  a  cotton  and  collodion 


This  constitutes  a  most  valuable  aid  in  ascertaining  the  character 
of  a  joint  effusion.  Therapeutic  puncture  of  joints  for  the  purpose 
of  injecting  fluids  in  the  treatment  of  tuberculous  synovitis  and 
acute  infections  involving  joints  is  also  becoming  a  frequent  opera- 
tion. Puncture  of  a  joint  is  not  difficult  if  the  joint  is  distended 
with  fluid.  Care  should  be  exercised  not  to  insert  the  needle  at  a 
point  where  blood-vessels  or  important  nerves  would  be  encountered 
and  to  avoid  producing  any  injury  to  the  cartilage  of  the  joint,  lest 
serious  complications  result. 

Apparatus. — Exploring  needles,  a  glass  aspirating  syringe,  a 
scalpel,  a  cocain  syringe,  etc.,  should  be  provided  (see  page  259). 

Asepsis. — Puncture  of  a  joint,  as  all  exploratory  punctures 
should  be  made  under  all  aseptic  precautions.  The  instruments 
are  to  be  sterilized  by  boiling,  the  operator's  hands  are  as  carefully 
prepared  as  for  any  operation,  and  the  site  of  puncture  is  painted 
with  tincture  of  iodin. 

Anesthesia. — Local  infiltration  is  employed. 

Technic. — The  skin  over  the  site  of  puncture  is  infiltrated  with  a 
0.2  per  cent,  solution  of  cocain  or  a  i  per  cent,  novocain  solution  and 
the  deeper  tissues  down  to  the  joint  capsule  are  similarly  anesthe- 
tized. A  small  nick  is  then  made  in  the  skin  at  the  point  chosen  for 
insertion  of  the  needle,  and  the  needle  is  inserted  into  the  joint  in  the 
same  manner  as  for  any  exploration  puncture. 

The  sites  for  puncture  of  those  joints  to  which  the  method  is 
most  often  apphed  are  as  follows: 

The  Shoulder=joint. — Entrance  to  the  joint  is  best  eft'ected  by 
introducing  the  needle  from  the  side  through  the  groove  between  the 
acromion  process  and  the  head  of  the  humerus.  The  direction  of  the 
needle  should  be  somewhat  downward  and  backward  (Fig.  273),  if  it 
is  inserted  straight  in  from  the  side  it  is  apt  to  enter  the  subacromial 

The  Elbow=joint. — Puncture  of  the  joint  may  be  made  from 
behind  or  from  the  outer  side. 

To  enter  the  joint  from  behind,  the  forearm  is  flexed  to  an  angle 



of  135  degrees,  and  the  needle  is  inserted  downward  and  forward 
behind  the  olecranon  (Fig.  274). 

To  pnnctiire  the  joint  from  the  outer  side,  the  arm  is  flexed  and 
the  radial  head  is  identified  by  the  finger  as  the  forearm  is  rotated. 
The  needle  is  then  inserted  into  the  joint  between  the  external  con- 
dyle of  the  humerus  and  the  head  of  the  radius. 

The  Wrist-joint. — The  joint  is  best  entered  from  the  dorsal  sur- 
face, inserting  the  needle  near  the  radius  between  the  tendons  of  the 

Fig.  273. — Point  for  puncturing 
the  shoulder- joint 

Fig.   274. — Point  for  puncturing  the 

extensor  indicis  and  the  extensor  longus  pollicis  at  the  level  of  a  line 
joining  the  styloid  process  of  the  radius  and  that  of  the  ulna. 

The  Hip-joint. — The  hip  may  be  readily  entered  by  the  exploring 
needle  from  in  front,  at  what  is  known  as  Biingner's  point,  or  from 
the  side. 

Anterior  puncture  is  performed  as  follows:  A  spot  is  chosen 
midway  on  a  line  joining  the  point  at  which  the  femoral  artery 
emerges  from  under  Poupart's  ligament  and  the  tip  of  the  great  tro- 
chanter (Fig.  275),  and,  wdth  the  femoral  artery  identified  by  the 
forefinger  of  the  left  hand  to  avoid  injuring  it.  the  needle  is  pushed 
directly  back  into  the  joint. 

For  a  lateral  puncture  the  leg  should  be  slightly  adducted.  The 
needle  is  then  pushed  into  the  joint  toward  the  median  fine  of  the 
body  from  the  side  just  above  the  great  trochanter  (see  Fig.  275). 

The  Knee=joint. — The  needle  may  be  inserted  into  either  side  of 
the  joint — but  preferably  in  the  outer  side—  beneath  the  patella  at  a 



point  where  fluctuation  or  distention  is  most  in  evidence.  When  the 
swelling  is  more  marked  above  the  patella,  the  needle  may  be  intro- 
duced from  above  downward  behind  the  bone  (Fig  276),  the  operator's 

Pig.  275. — Points  for  puncturing   the   hip-joint    (modified    from   Pels-Leusden). 

left  hand  grasping  the  joint  below  the  patella  and  forcing  the  intra- 
articular fluid  upward  into  the  suprapatellar  recess. 

The  Ankle=joint. — To  avoid  injuring  the  vessels  and  nerves 
which  lie  opposite  the  middle  of  the  joint,  the  needle  should  be  intro- 

FiG.  276. — Point  for  puncturing  the  knee-joint 

duced  from  in  front  midway  between  the  bundle  of  tendons  which 
pass  in  front  of  the  joint  and  the  corresponding  malleolus.  On  the 
inner  side  the  needle  is  inserted  1/2  inch  (i  cm.)  above  the  malleolar 



process  in  a  direction  obliquely  outward  and  backward;  on  the  outer 
side  the  needle  enters  3/4  of  an  inch  (2  cm.)  above  the  malleolar 
process  in  a  direction  obHquely  inward  and  backward. 


Lumbar  puncture,  anx)peration  first  proposed  by  Quincke  for  the 
withdrawal  of  cerebrospinal  fluid  from  the  spinal  canal,  has  both 
diagnostic  and  therapeutic  value.  This  procedure  is  of  diagnostic 
importance  through  the  information  that  may  be  obtained  in  estimat- 
ing the  pressure  of  the  cerebrospinal  fluid  and  determining  its  char- 

FiG.  277. — Anatomy  of  the  lumbar  vertebra. 

acteristics  by  physical,  chemical,  microscopical,  and  bacteriological 

Among  its  therapeutic  uses  is  its  employment  as  a  "decom- 
pressive agent,"  in  cases  of  meningitis,  hydrocephalus,  intracranial 
tumors,  cerebral  abscess,  uremia,  etc.,  etc.  On  account  of  the  con- 
tinuity of  the  spaces  in  the  brain  and  spinal  column,  temporary  rehef 
of  intracranial  and  intraspinal  pressure  may  be  obtained  in  the  above 
cases  by  the  withdrawal  of  small  amounts  of  fluid  from  the  spinal 
canal.  Lumbar  puncture  should  be  employed  with  great  caution, 
however,  in  cases  of  brain  tumor,  for  sudden  death  may  follow 
removal  of  a  large  amount  of  fluid,  the  increased  intracranial  tension 
causing  the  medulla  to  be  forced  against  the  foramen  magnum  when 
the  intraspinal  pressure  is  reheved.  In  cerebrospinal  meningitis, 
drainage  by  lumbar  puncture  is  often  followed  by  good  results^  as 



not  only  is  the  pressure  upon  the  cord  and  cerebral  centers  lessened, 
but  pus  is  withdrawn,  and  the  toxicity  of  the  spinal  fluid  is  thereb}' 

It  is  in  the  administration  of  antitetanic  serum  and  antiserum 
in  cerebrospinal  meningitis,  and  the  production  of  spinal  anes- 
thesia, however,  that  lumbar  puncture  finds  its  chief  therapeutic 

Fi(..   278. — -Stylet  needle  for  spinal  jjuncture. 

•Anatomy. — In  the  lumbar  portion  of  the  vertebral  column  the  spi- 
nous processes  do  not  project  downward  to  such  a  degree  as  in 
other  portions,  and  there  is  a  distinct  space  (about  7/8  inch  (22  mm.) 
in  the  transverse  and  3/5  inch  (15  mm.)  in  the  vertical  diameter) 
between  the  vertebral  arches  filled  with  ligaments  through  which  a 
needle  may  be  readily  passed  into  the  spinal  canal  (Fig.  277.)     The 


IX  3  ^ 

Pig.  279,     Apparatus  tor  spinal  puncture,      i,  Scalpel;  2,  ethyl  chlorid  tube;  3, 
small  glass  graduate;  4,  hydrometer;  5    sterile  test-tube;  6   culture  tubes. 

spinal  cord  reaches  only  to  the  second  lumbar  vertebra,  so  if  the  punc- 
ture be  made  below  that  point,  and  the  introduction  of  the  needle  be 
carried  out  under  rigid  asepsis  the  operation  is  practically  harmless. 
The  Needle. — The  puncture  is  best  made  with  a  special  stylet 
needle  devised  for  the  purpose.  It  should  be  of  platinum  or  nickel,  at 
least  3  1/2  inches  (9  cm.)  long  and  about  1/25  of  an  inch  (i  mm.)  in 



diameter,  and  the  point  should  be  short  and  ground  almost  squarely 
across  (Fig.  278).  In  the  absence  of  such  a  needle,  the  ordinary 
aspirating  needle  of  about  the  same  size  may  be  substituted.  In 
addition,  a  scalpel,  a  sterilized  graduated  test-tube,  culture  tubes, 
and  an  ordinary  hydrometer  (Fig.  279)  will  be  required.  When  it 
is  desired  to  estimate  accurately  the  cerebrospinal  pressure,  a  small 
mercury  manometer  will  also  be  required. 

Location  of  the  Puncture. — ^The  space  between  the  third  and 
fourth  or  that  between  the  fourth  and  fifth  lumbar  vertebrae  is  usually 
chosen  (Fig.  280),  though,  if  the  puncture  is  performed  for  diagnostic 
purposes,  it  may  be  made  lower — between  the  fifth  lumbar  and  first 
sacral  vertebrae  in  order  to  withdraw  any  sediment  that  may  be 
present.     A  point  just  below  the  tip  of  the  spinous  process  of  the 

Fig.   280. — Points  for  spinal  puncture. 

vertebra  forming  the  upper  boundary  of  the  chosen  interspace  at  a 
distance  of  about  1/2  inch  (i  cm.)  to  one  side  of  the  median  line  is 
selected  for  the  insertion  of  the  needle.  In  children,  however,  the 
spinous  processes  being  short,  the  needle  may  be  inserted  in  the 
median  line. 

The  spinous  processes  may  be  readily  identified  by  counting  down 
from  the  seventh  cervical  vertebra,  unless  the  individual  be  very 
stout.  If,  however,  any  difficulty  is  experienced  in  locating  this 
vertebra,  the  landmarks  may  be  quickly  determined  by  passing  a 
transverse  line  between  the  highest  points  of  the  iliac  crests  with  the 
patient  standing  erect,  and  it  will  be  found  that  such  a  line  passes 
through  the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra 
(Fig.  281). 



Position  of  the  Patient. — The  operation  may  be  performed  with 
the  patient  sitting  in  a  chair,  with  the  body  bent  well  forward  in  the 
form  of  a  curve  (Fig.  282),  so  as  to  widen  the  intervertebral  spaces  as 

Fig.  281. — Showing  the  method  of  locating  the  fourth  spinous  process  by  passing  a 
line  through  the  highest  points  of  the  iliac  crests. 

much  as  is  possible.  If  this  is  impracticable,  the  patient  may  lie  on 
his  left  side  with  his  knees  drawn  up,  shoulders  forward,  and  body 
bent  forward  in  an  arch  (Fig.  283). 

Fig.   282. — -Sitting  posture  for  spinal  puncture. 

Asepsis. — The   site   for   the  puncture   should   be  painted   with 
iodin,  and  thorough   asepsis   must   be   observed   during   the   entire 



operation.     The  needle  should  be  boiled  and  the  operator's  hands 
should  be  properly  sterilized. 

Anesthesia. — With  children  general  anesthesia  may  be  necessary. 
In  other  cases,  local  anesthesia  with  a  0.2  per  cent,  solution  of  cocain 

Fig.   283. — Lateral  position  for  spina]  puncture. 

or  a  I  per  cent,  novocain  solution,  or  by  freezing,  as  for  any  puncture, 
will  answer  all  purposes. 

Technic. — To  avoid  contaminating  the  needle  by  the  bacteria 
of  the  skin  as  well  as  to  make  the  insertion  of  the  rather  blunt  needle 
easier,  a  puncture  should  be  made  with  a  scalpel  through  the  skin  at 

Fig.  284. — Spinal  puncture.     First  step,  nick-      Fig.   285. — Spinal  puncture.     See- 
ing the  skin  at  the  point  of  puncture.  end  step,  inserting  the  needle. 

the  chosen  spot  (Fig.  284).  The  operator's  left  thumb  or  index  finger 
is  then  placed  between  the  two  spinous  processes  as  a  guide,  and  the 
point  of  the  needle  is  inserted  on  the  same  level  as  the  finger  about  1/2 
inch  (i  cm.)  from  the  median  line,  in  an  upward  and  inward  direction 


(Fig.  285).  until  it  enters  the  spinal  canal.  In  a  child  this  will  usu- 
ally occur  at  a  depth  of  from  3/4  to  i  1/2  inches  (about  2  to  4  cm. ) 
and  in  an  adult  from  2  1/2  to  3  inches  (about  6  to  7.5  cm.).  If  the 
needle  strikes  bone,  it  should  be  shghtly  withdrawn  and  then  rein- 
serted, its  direction  being  changed  somewhat. 

As  soon  as  the  canal  is  entered,  the  stylet  is  withdrawn,  and  the 
fluid,  as  it  oozes  from  the  needle  drop  by  drop,  is  collected  in  a  sterile 
test-tube  (Fig.  286).  The  first  few  drops  are  usually  blood  stained, 
and,  if  so,  they  should  be  discarded.  Not  more  than  i  1/4  drams 
(about  5  c.c.)  of  fluid  should  be  withdrawn  from  the  spinal  canal  of  a 

Fig.   286. — .Spinal  puncture.     Third  step,  collecting  the  cerebrospinal  fluid. 

child,  nor  more  than  1/2  ounce  (15  c.c.)  from  an  adult,  at  one  time 
for  diagnostic  purposes.  When,  however,  the  puncture  is  performed 
to  relieve  intracranial  pressure,  from  i  ounce  to  i  1/2  ounce  (30  to 
45  c.c.)  of  fluid  may  be  removed,  according  to  the  tension,  and  even 
more  if  no  ill  effects  are  observed.  Withdrawal  of  too  much  fluid 
may  cause  dizziness,  pallor,  sweating,  and  vomiting  and  later  a 
sharp  headache.  A  dry  puncture  is  sometimes  encountered  and  may 
be  due  to  the  needle  not  entering  the  canal,  to  its  being  plugged,  or 
from  the  fluid  being  too  thick  to  flow  through  its  lumen. 

At  the  completion  of  the  operation,  the  site  of  puncture  is  sealed 
with  collodion  and  cotton  and  the  patient  is  kept  recumbent  in  bed 
for  24  hours. 

Normal  Cerebrospinal  Fluid  and  its  Pathological  Variations. — 
Normally,  the  cerebrospinal  fluid  escapes  slowly,  while  in  certain 
diseased  conditions  with  increased  pressure,  as  meningitis,  tumor  of 
the  brain,  uremia,  paresis,  hydrocephalus,  etc.,  and  in  certain  infec- 


tious  diseases,  it  may  spurt  out.  The  pressure  may  be  roughly 
estimated  by  the  strength  of  the  flow  from  the  needle,  a  strong  spurt 
of  fluid  indicating  an  increased  amount  of  pressure,  and  very  slow- 
coming  drops  the  reverse.  It  may  be  more  accurately  measured  by 
attaching  to  the  needle  a  small  mercury  manometer  by  a  smaU  rubber 
tube,  8  to  16  inches  (20  to  40  cm.)  long,  filled  with  a  i  per  cent,  solu- 
tion of  carbolic  acid.  This,  of  course,  is  to  be  done  before  any  of  the 
fluid  is  permitted  to  escape.  According  to  Sahli.  the  normal  dural 
pressure  in  the  horizontal  position  is  60  to  100  mm.  of  water  (5  to  7.3 
mm.  of  mercury),  and  200  to  800  mm.  of  water  (15  to  60  mm.  of 
mercury)  in  certain  pathological  conditions. 

Normal  cerebrospinal  fluid  is  colorless  and  water-like  in  clearness, 
of  alkaline  reaction,  has  a  specific  gravity  of  1006  to  1008  and  exists 
in  the  spinal  canal  in  but  small  amounts,  varying  between  1/2  and  2 
ounces  (15  and  60  c.c.)  in  adults  and  in  infants  between  2  1/2  and  5 
drams  (10  and  20  c.c).  In  certain  infectious  diseases,  intracranial 
tumor,  meningitis,  hydrocephalus,  general  paresis,  etc.,  the  amount 
of  cerebrospinal  fluid  may  be  greatly  increased.  It  contains  but 
little  albumin  (0.02  to  0.05  per  cent.),  some  chlorids  (0.7  per  cent.), 
a  copper-reducing  body  claimed  to  be  glucose,  and  traces  of  urea 
(0.035  to  0.04  per  cent.).  In  nephritis  and  uremia,  the  urea  is 
largely  increased  and  the  amount  of  chlorids  may  rise  slightly;  in 
hydrocephalus  there  may  be  a  shght  increase  in  the  urea.  In  apo- 
plexy, meningitis,  paresis,  hydrocephalus,  and  brain  tumor,  the  quan- 
tity of  albumin  may  be  markedly  increased.  A  bloody  or  blood- 
stained fluid  will  be  found  in  intrameningeal  cranial  hemorrhages  and 
in  injuries  of  the  skull  extending  through  the  dura,  but  in  injuries 
outside  the  dura  the  fluid  will  be  clear;  bloody  fluid  may  also  occur  in 
meningitis.  In  jaundice  it  may  be  greenish-yellow  in  color.  A 
cloudy,  purulent  fluid  indicates  inflammation  of  the  meninges,  as  does 
a  rise  in  the  specific  gravity,  and  the  appearance  of  white  blood 
cells  on  examination.  In  tubercular  meningitis,  however,  the  fluid  is 
clear  and  limpid,  and  there  is  present  a  high  lymphocytosis.  It  is 
only  possible  to  determine  the  specific  form  of  infection  by  bacterio- 
logical examination.  Identification  of  the  diplococcus  intracellularis, 
pneumococcus,  streptococcus,  or  tubercle  bacilli  \^'ill  definitely  settle 
the  nature  of  the  infection. 

Lumbar  Puncture  as  a  Means  of  Administering  Antitoxic 
Sera. — When  lumbar  puncture  is  employed  for  the  purpose  of  ad- 
ministering sera  in  tetanus  and  cerebrospinal  meningitis,  a  fairly  large 
syringe,  one  with  a  capacity  of  at  least  i  ounce  (30  c.c),  is  required  in 


addition  to  the  other  instruments  necessary  for  spinal  puncture.  The 
puncture  is  made  in  the  manner  described  above,  and  a  quantity  of 
cerebrospinal  fluid  equal  to  the  amount  of  serum  to  be  injected  is 
allowed  to  escape  from  the  canal;  the  serum  is  then  warmed  and  is 
slowly  injected  through  the  same  needle  employed  for  the  puncture. 

In  cases  of  tetanus,  Rogers  {Journal  oj  the  American  Medical 
Association,  July  i,  1905).  injects  2  1/2  to  5  drams  (10  to  20  c.c.)  of 
an ti tetanic  serum  into  the  nerves  of  the  cauda  equina,  as  well  as 
subcutaneously  in  the  neighborhood  of  the  wound,  intravenously,  and 
into  the  nerves  of  the  brachial  plexus  if  the  site  of  infection  is  upon  the 
upper  extremity,  and  into  the  sciatic  and  anterior  crural  nerves  if  the 
wound  is  in  the  lower  extremity.  In  making  the  spinal  injection  the 
needle  is  inserted  in  the  space  between  the  second  and  third  lumbar 
vertebrae,  so  as  to  strike  the  cauda  equina,  and  is  manipulated  back 
and  forth  with  the  object  of  wounding  some  of  the  nerves,  which  is 
manifested  by  twitching  of  the  legs;  2  1/2  to  5  drams  (10  to  20  c.c.) 
of  serum  are  then  injected  into  and  around  these  injured  nerves. 

For  cases  of  cerebrospinal  meningitis,  i  to  i  1/2  ounces  (30  to 
45  c.c.)  of  serum  are  injected  into  the  third  or  fourth  lumbar  space 
after  a  like  amount  of  cerebrospinal  fluid  has  been  evacuated.  Sub- 
sequent injections  are  given  at  intervals  of  twelve  to  twenty-four 
hours,  according  to  the  severity  of  the  case,  for  three  or  four  days.  If 
after  a  lapse  of  several  days  the  symptoms  return,  another  series  of 
injections  is  given.  In  place  of  a  syringe,  a  glass  funnel  holding 
about  5  drams  (20  c.c.)  attached  to  the  needle  by  rubber  tubing  may 
be  employed  for  administering  the  serum,  as  advised  by  Koplik. 



Paracentesis  thoracis,  also  spoken  of  as  thoracentesis  and  pleuro- 
centesis,  consists  in  the  evacuation  of  fluid  from  the  pleural  cavities 
by  means  of  a  hollow  needle  or  trocar  to  which  an  aspirator  is 

Indications. — When  the  presence  of  fluid  has  been  made  out  by 
the  physical  signs  and  the  diagnosis  verified  by  an  exploratory  punc- 
ture, thoracentesis  is  indicated  in  sero-fibrinous  effusions  under  the 
following  conditions: 

1.  When  the  fluid  is  sufficient  to  produce  dyspnea,  cyanosis,  and 
cardiac  weakness. 

2.  In  very  large  effusions  whether  or  not  pressure  symptoms 
are  present,  especially  if  bilateral. 

3.  When  the  heart  is  displaced  by  the  presence  of  fluid. 

4.  When  the  fluid  is  not  absorbed  within  a  week  or  ten  days  in 
spite  of  medical  treatment. 

The  advantages  of  early  aspiration  are  that  adhesions  may  be 
prevented  and  the  course  of  the  disease  considerably  shortened. 
Long  continued  pressure  upon  the  lung  by  an  effusion  may  prevent 
its  subsequent  full  expansion,  and  reappearance  of  the  fluid  is  more 
apt  to  occur  when  the  operation  has  been  delayed. 

Apparatus,  Etc.— Evacuation  of  the  fluid  is  accomplished  by 
means  of  suction;  for  this  purpose  a  hollow  needle  or  a  trocar  con- 
nected with  either  an  aspirator  or  a  syphonage  apparatus  may  be 
employed.  In  addition,  a  scalpel,  and  collodion  and  cotton,  or  a 
pad  of  sterile  gauze  and  adhesive  plaster  for  the  dressing,  should 
be  supplied. 

The  Aspirating  Needle. — Whether  an  ordinary  aspirating  needle 
or  trocar  and  cannula  be  employed  does  not  make  any  material 
difference,  though  the  latter  has  some  advantages.  Where  the  tro- 
car form  of  needle  is  employed  the  point  of  the  cannula  may  be 
moved  about  without  danger  after  the  stylet  is  removed,  and,  should 
the  lumen  of  the  cannula  become  plugged,  the  obstacle  may  be  re- 




moved  without  the  necessity  of  withdrawing  the  cannula  b\'  simple- 
reinserting  the  stylet.  With  an  aspirating  needle,  on  the  other  hand, 
the  unprotected  point  of  the  needle  may  injure  the  lung  or  diaphragm, 
and,  furthermore,  should  the  lumen  of  the  needle  become  blocked, 
it  may  be  necessary  to  withdraw  it  entirely  in  order  to  clear  out  the 
obstruction.  If  an  aspirating  needle  is  used,  one  should  be  chosen  at 
least  3  inches  (7.5  cm.)  long  and  from  1/25  inch  (i  mm.)  to  1/12 
inch  (2  mm.)  in  diameter  depending  upon  the  consistency  of  the 
material  to  be  evacuated. 

In  a  properly  made  trocar  the  stylet  should  fit  the  point  of  the 
cannula  accurately,  and  the  cannula  and  stylet  should  gradually 
taper  to  a  point,  as  if  in  one  piece.  The  cannula  is  provided  with  a 
stopcock  near  the  proximal  end  to  prevent  leakage  of  air  when  the 
stylet  is  withdrawn,  while  a  lateral  opening,  for  connection  with  the 
aspirator,  is  placed  at  a  point  distal  to  this  stopcock,  so  that  the  sty- 
let may  be  moved  back  and  forth  without  disturbing  the  connections 
(Fig.  287). 

Fig.   287. — Aspirating  trocar. 

Aspirators. — The  Potain,  the  Dieulafoy,  or  the  heat  vacuum 
apparatus  is  most  commonly  employed,  though  the  aspiration  may 
be  satisfactorily  made  in  a  large  proportion  of  cases  by  simple 
sjphonage.  The  Dieulafoy  instrument  is  most  convenient  for 
evacuating  small  collections  of  fluid  and  when  it  is  desirable  to  be  exact 
in  the  quantity  removed,  while  for  large  effusions  the  Potain  or  the 
heat  vacuum  apparatus  is  best. 

The  Potain  instrument  (Fig.  288)  consists  of  an  exhausting  pump. 
a  large  glass  bottle,  a  rubber  stopper  through  which  passes  the  long 
arm  of  a  Y-shaped  metal  tube  with  a  stopcock  in  each  limb,  and  two 
pieces  of  heavy  rubber  tubing,  one  connecting  the  needle  or  trocar 
with  one  arm  of  the  Y.  and  the  other  joining  the  second  arm  and  the 
exhausting  pump.  The  instrument  is  assembled  by  inserting  the 
stopper  firmly  into  the  glass  receptacle  and  attaching  one  end  of  a 
piece  of  tubing  to  the  stopcock  a  and  the  other  to  the  needle  or 



trocar.  By  means  of  the  second  tubing  the  exhausting  syringe  is 
connected  with  stopcock  h.  The  instrument  should  be  carefully 
tested  before  using  to  see  that  all  the  connections  are  air-tight.  To 
produce  a  vacuum,  stopcock  a  is  closed  and  stopcock  h  is  opened, 

Fig.  288. — Potain  aspirator. 

when,  by  pumping  from  thirty  to  fifty  strokes,  the  air  will  be  suffi- 
ciently exhausted.  Stopcock  h  is  then  closed,  and  the  needle  is 
inserted  into  the  chest.  As  soon  as  its  point  enters  the  tissues,  the 
vacuum  is  extended  to  the  point  by  opening  stopcock  a,  so  that  the 
moment  fluid  is  reached  it  will  be  drawn  by  suction  into  the  bottle= 

Fig.  289. — The  Dieulafoy  aspirator. 

If  the  trocar  is  employed,  the  stylet  is  not  withdrawn  until  the  tro- 
car enters  the  chest;  as  this  is  done  the  stopcock  on  the  cannula  is 
closed,  so  as  to  exclude  air. 

The  Dieulafoy  apparatus  (Fig.  289)  consists  of  a  glass  syringe. 


with  a  capacity  of  3  to  4  ounces  (90  to  120  c.c),  provided  with  two 
outlets,  each  furnished  with  a  stopcock,  and  to  which  are  fitted 
heavy  rubber  tubes.  To  the  extremity  of  one  tube  a  trocar  or 
aspirating  needle  is  attached,  and  at  a  distance  of  about  4  inches 
(10  cm.)  from  the  needle  end  a  piece  of  glass  tubing  is  inserted  as  an 
index.  The  other  piece  of  tubing  leads  from  stopcock  &  to  a  basin 
to  carry  ofif  the  fluid  discharged  from  the  cylinder.  To  use  the  in- 
strument both  stopcocks  are  closed,  and  the  piston  is  fully  withdrawn 
and  fixed  in  place  by  a  spring.     This  produces  the  vacuum.     The 

Fig.  290. — Connell's  heat  vacuum  aspirator. 

aspirating  needle  is  then  introduced  in  the  chosen  site,  and,  as  soon 
as  the  needle  point  is  buried  in  the  tissues,  the  stopcock  a  is  opened, 
allowing  the  vacuum  to  extend  to  the  needle.  The  needle  is  then 
pushed  on  in  until  it  enters  the  chest,  the  presence  of  fluid  being  first 
demonstrated  as  it  passes  through  the  glass  index.  When  the  aspi- 
rator is  filled,  stopcock  a  is  closed  and  stopcock  b  opened,  and  the 
fluid  is  discharged  from  b  by  driving  the  piston  back  in  place.  This 
process  of  aspiration  may  be  repeated  as  often  as  necessary  without 
removing  the  needle  or  disconnecting  the  aspirator. 

A  very  excellent  form  of  aspirator  and  one  that  is  frequently 
employed  is  the  vacuum  bottle  described  by  Connell  {Medical 
Record,  July  4,   1903).     It  consists  of  a  strong  glass  bottle  with  a 



capacity  of  about  5  pints  (2.5  liters),  having  a  mouth  i  inch  (2.5 
cm.)  wide,  fitted  with  a  rubber  stopper  through  which  passes  a  glass 
tube  with  a  heavy  piece  of  rubber  tubing  attached,  ending  in  an 
aspirating  needle.  Three  drams  (12  c.c.)  of  95  per  cent,  alcohol  are 
poured  into  the  bottle  which  is  so  manipulated  that  its  inner  surface 
is  entirely  coated,  when  the  excess  of  alcohol  is  poured  off.  The 
alcohol  is  then  ignited,  and,  as  the  flame  reaches  the  bottom  of  the 
bottle,  the  cork  is  quickly  inserted,  the  rubber  tubing  having  been 
previously  clamped  (Fig.  290).  A  vacuum  is  thus  produced  which 
is  amply  sufficient  to  aspirate  a  chest. 

Removal  of  an  effusion  by  syphonage  may  be  readily  accom- 
pHshed  by  means  of  a  very  simple  apparatus.  A  piece  of  heavy 
tubing  about  3  feet  (90  cm.)  long,  a  clamp  to  close  one  end  of  the 

Fig.  291. — Syphonage  aspirator. 

tubing,  a  funnel,  sterile  water  or  sahne  solution  to  fill  the  tubing,  and 
a  receptacle  to  collect  the  fluid  are  the  necessary  requisites.  One 
end  of  the  tubing  is  fastened  to  a  large  caliber  needle  or  the  side  out- 
let of  the  trocar  and  the  other  to  the  glass  funnel  (Fig.  291). 

Site  of  Aspiration. — The  needle  should  be  inserted  at  a  point  where 
the  physical  signs  or  an  exploratory  puncture  demonstrate  the 
presence  of  fluid  and  at  the  lowest  level  of  the  fluid,  that  its  with- 
drawal may  be  facihtated  as  far  as  possible  by  the  action  of  gravity. 
The  sixth  intercostal  space  in  the  anterior  axiflary  fine,  the  sixth  or 
seventh  space  in  the  midaxillary  fine,  and  the  eighth  space  below 
the  angle  of  the  scapula  are  the  points  of  election  (Fig.  292). 

Quantity  Withdrawn. — It  is  not  essential  to  empty  the  chest  en- 
tirely at  one  sitting.  The  amount  of  fluid  evacuated  should  be  deter- 



mined  more  by  the  manner  in  which  the  patient  bears  the  operation, 
the  condition  of  the  pulse,  and  signs  of  impending  collapse  rather  than 
by  the  quantity  of  fluid  present.  In  very  large  effusions  as  much  as 
3  pints  (1500  c.c.)  may  be  removed,  but  it  is  better  to  withdraw 
too  little  than  too  much,  for  what  remains  may  be  evacuated  at  a 
subsequent  period;  and  it  not  infrequently  happens  that  spontaneous 
absorption  of  the  eft'usion  follows  the  removal  of  even  small 

Position  of  Patient. — The  aspiration  is  preferably  performed  with 
the  patient  on  a  bed  so  as  to  avoid  the  extra  exertion  of  moving  after 

Fig.  292. — Sites  for  aspiration  of  the  pleura.     (The  large  dots  represent  the  points 

of  election.) 

the  operation.  When  possible,  an  upright  sitting  position  should 
be  assumed,  with  the  arm  of  the  affected  side  raised,  and  the  hand 
placed  on  some  support  or  on  the  opposite  shoulder  to  increase  the 
breadth  between  the  intercostal  spaces  (Fig.  293).  If  this  is  im- 
practicable, the  patient  may  lie  near  the  edge  of  the  bed,  upon  the 
back  for  a  lateral  puncture,  or  rolled  slightly  to  the  opposite  side  with 
the  arm  extended  over  the  head  for  a  posterior  puncture  (see  Fig.  262). 
Asepsis. — The  skin  at  the  site  of  operation  should  be  painted  with 
tincture  of  iodin;  the  operator's  hands  should  also  be  properly 
cleansed,  and  the  needle  or  trocar  sterilized  by  boiHng. 



Anesthesia. — Local  anesthesia  by  freezing  with  ethyl  chlorid  or 
by  infiltration  with  a  few  drops  of  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  solution  of  novocain  at  the  point  of  puncture  will  be 

Fig.   293. — Position  of  patient  for  aspiration  of  the  pleura. 

Technic. — A  vacuum  is  first  produced  in  the  aspirator  and  the 
needle  or  trocar  attached.  A  point  is  then  selected  in  the  chosen 
interspace  at  a  little  distance  from  the  upper  margin  of  the  lower  rib 
bounding  the  space,  so  as  to  avoid  the  upper  intercostal  artery,  and 
the  skin  is  nicked  with  a  scalpel.     The  thumb  and  forefinger  of  the 

Fig.  294. — Method  of  holding  the  trocar. 

left  hand  are  used  to  steady  the  tissues  overlying  the  intercostal 
space,  while  the  needle  or  trocar  is  introduced  with  the  right  hand,  the 
forefinger  being  placed  on  the  needle  to  guard  against  its  being  in- 
serted too  deeply  (Fig.  294).  As  soon  as  the  point  of  the  needle 
enters  the  tissues,  the  vacuum  already  present  in  the  aspirator  is 



extended  to  the  needle  point  by  opening  the  proper  stopcock,  and  the 
needle  is  steadily  pushed  in  until  it  enters  the  pleural  sac,  which  will 
usually  be  at  a  depth  of  less  than  2  inches  (5  cm.).  The  fluid  should 
be  withdrawn  rather  slowly  in.  order  that  the  structures  may  have 
time  to  adjust  themselves  to  the  changed  conditions  in  the  chest; 
at  least  twenty  minutes  to  half  an  hour  should  be  consumed  in  re- 
moving 2  pints  fiooo  c.c). 

Should  the  patient  feel  faint  or  sufifer  from  vertigo  or  dyspnea 
the  operation  should  be  temporarily  interrupted  and  the  patient's 

Fig.   295. — Aspiration  of  the  pleura  with  the  Potain  apparatus. 

head  lowered.  Complaints  of  severe  pain,  persistent  cough,  or 
expectoration  of  blood  also  demand  that  the  aspiration  be 

At  the  completion  of  the  operation  the  tissues  are  pinched  up 
around  the  shaft  of  the  needle  which  is  quickly  withdrawn.  The 
site  of  puncture  is  then  dressed  with  collodion  and  cotton,  or  with  a 
sterile  pad  of  gauze  held  in  place  by  adhesive  strips. 

In  employing  the  sj-phonage  apparatus  the  tubing  is  first  filled 
with  sterile  solution,  and  the  clamp  is  placed  near  the  end  of  the  tube 
to  prevent  the  solution  escaping.  The  needle  is  then  introduced 
into  the  chest,  while  the  free  end  of  the  tube  is  placed  under  water 
in  the  receptacle  provided  for  the  collection  of  the  fluid.     On  remov- 


ing  the  clamp  from  the  tube  the  column  of  water  is  released  and  the 
fluid  withdrawn  by  a  process  of  syphonage. 

Complications  and  Dangers. — Sepsis  is  not  to  be  feared  if  the 
ordinary  aseptic  precautions  are  observed. 

Pneumothorax  may  follow^  injury  to  the  lung  by  the  aspirating 
needle  or  trocar,  or  be  due  to  the  rupture  of  adhesions  or  a  cavity 
when  expansion  occurs,  or  to  the  entrance  of  air  along  the  trocar. 

Albuminous  expectoration  has  been  observed  as  a  sequel  to  the 
sudden  withdrawal  of  large  quantities  of  fluid.  The  expectoration 
consists  of  a  yellow^ish.  frothy  fluid,  and  it  is  accompanied  by  dysp- 
nea, cyanosis,  and  a  weak  pulse.  This  condition  usually  begins 
during  the  withdrawal  of  the  fluid,  or  comes  on  shortly  afterward. 
It  is  explained  on  the  supposition  that  the  rapid  withdrawal  of  fluid 
suddenly  removes  the  pressure  from  the  lung,  which  as  a  result 
becomes  congested,  and  transudation  into  the  air  cells  follows. 

Expectoration  of  blood  may  result  from  the  rupture  of  small  pul- 
monary vessels,  from  congestion  of  the  lung,  or  from  injury  to  the 
lung  tissue  by  the  aspirating  needle. 

Sudden  death  is  unusual,  though  it  may  occur,  and  at  times  with- 
out apparent  cause.  EmboHsm,  cerebral  anemia,  from  the  sudden 
rush  of  blood  to  the  expanding  lung,  hemorrhage  into  the  pleural 
cavities  from  injury  to  the  lung,  and  irritation  of  the  terminations  of 
the  pneumogastric  nerve  have  been  suggested  as  explanations. 

The  occurrence  of  these  complications  may  be  reduced  to  a 
minimum  by  the  employment  of  rigid  asepsis,  the  observance  of 
great  care  in  the  use  of  the  needle  or  trocar,  and  the  removal  of  only 
moderate  amounts  of  fluid  without  haste. 


Paracentesis  pericardii,  or  pericardicentesis,  consists  in  the  evacu- 
ation of  the  contents  of  the  pericardial  sac  through  aspiration  by 
means  of  a  needle  or  a  fine  trocar  attached  to  a  vacuum  apparatus. 

Indications. — Paracentesis  of  the  pericardium  should  be  per- 

1.  If  the  eft'usion  is  sufficiently  large  to  endanger  Hfe  through 
profound  disturbance  in  the  cardiac  action  indicated  by  severe 
dyspnea,  small,  rapid,  and  irregular  pulse,  and  cyanosis,  the  indicatio 
vitalis,  as  death  may  result  from  syncope  if  the  condition  be  not 
relieved  without  delay. 

2.  When  a  large  effusion  does  not  show  any  tendency  to  absorp- 
tion after  a  prolonged  and  fair  trial  of  medical  means. 



In  the  presence  of  a  purulent  exudate,  though  temporary  relief 
may  be  obtained  by  aspiration,  the  condition  is  one  that  should  be 
treated  by  incision  and  free  drainage,  just  as  in  empyema. 

Apparatus,  Etc, — In  tapping  the  pericardium  a  Potain  or  Dieu- 
lafoy  aspirator  to  which  is  attached  a  fine  needle  or  trocar  and  can- 
nula may  be  employed  in  the  same  way  as  used  in  the  pleural  cavity; 
a  scalpel,  collodion  and  cotton,  or  gauze  and  adhesive  plaster  for 
the  purpose  of  dressings,  should  also  be  at  hand. 

Site  of  Aspiration. — The  point  for  making  the  aspiration  should 
be  determined  upon  after  having  first  detected  the  presence  of  fluid 

V     \  ~ i- 

5>\  ^ — -y^^y^r^ 

I  '\  V    y    --/ 
\  W  ~'     /' 

Fig.  296. — Points  for  aspiration  of  the  pericardium.  The  dotted  line  indicates 
a  distended  pericardial  sac.  The  course  of  the  internal  mammary  vessels  is  also 

by  an  exploratory  puncture  (page  265).     For  the  introduction  of  the 
needle  there  are  four  sites  recommended: 

1.  In  the  fourth  or  fifth  intercostal  space  close  to  the  left  sternal 
margin,  or  else  i  inch  (2.5  cm.)  to  the  left  of  it,  thus  passing  either 
internal  or  external  to  the  internal  mammary  artery. 

2.  In  the  fifth  interspace  close  to  the  right  of  the  sternum. 

3.  Close  to  the  costal  margin  in  the  angle  between  the  ensiform 
cartilage  and  seventh  costal  cartilage  on  the  left,  inserting  the  needle 
upward  and  backward. 


4.  In  the  fifth  or  sixth  left  interspace  outside  the  nipple  line  be- 
tween the  apex  beat  and  outer  border  of  dullness  (Fig.  296), 

Quantity  Withdrawn. — In  small  effusions  the  fluid  may  be  re- 
moved at  one  sitting;  but  in  large  effusions,  in  order  to  avoid  suddenly 
removing  the  extracardial  pressure,  it  is  preferable  to  withdraw  not 
more  than  3  to  4  ounces  (90  to  120  c.c.)  at  the  first  sitting.  Thij 
may  be  followed  by  absorption  of  the  rest  of  the  fluid,  as  is  often  thf. 
case  in  pleurisy.  If  there  is  no  improvement  at  the  end  of  a  day  01 
two,  however,  it  will  be  necessary  to  perform  a  second  tapping. 

Position  of  Patient. — The  operation  may  be  performed  either  with 
the  patient  recumbent  or  sitting  upright. 

Asepsis. — The  greatest  regard  to  aseptic  precautions  should  be 
observed.  The  area  of  operation  should  be  shaved,  if  necessary,  and 
the  skin  painted  with  tincture  of  iodin.  The  operator's  hands  are 
thoroughly  cleansed,  and  the  apparatus  to  be  used  in  the  operation  is 

Anesthesia. — ^Local  anesthesia  by  freezing  with  ethyl  chlorid 
or  other  freezing  agents,  or  by  injecting  a  few  drops  of  a  0.2  per  cent, 
solution  of  cocain  or  a  i  per  cent,  solution  of  novocain  into  the  skin 
will  be  found  useful. 

Technic. — A  nick  is  made  through  the  skin  with  a  scalpel  at  a 
point  not  far  from  the  upper  margin  of  the  rib  forming  the  lower 
boundary  of  the  space  previously  determined  upon  for  aspiration. 
The  tissues  are  steadied  between  the  thumb  and  forefinger  of  the 
left  hand,  and  the  needle  is  held  in  the  right  hand,  the  index  finger 
being  placed  on  its  shaft  as  a  guide  to  the  proper  depth  of  insertion, 
as  shown  in  Fig.  294,  The  direction  of  the  needle  as  it  is  introduced 
should  be  at  first  backward,  until  it  enters  the  thorax,  and  then 
slightly  inward  into  the  pericardium;  but  if  the  approach  is  made 
in  the  left  seventh  costoxyphoid  angle,  the  needle  is  introduced 
directly  upward  and  backward.  The  introduction  of  the  needle 
must  be  performed  slowly,  steadily,  and  with  great  care.  The 
vacuum  previously  produ^ced  in  the  aspirator  is  extended  to  the 
needle,  by  opening  the  proper  valve,  as  soon  as  the  needle  point  enters 
the  tissues,  so  that  fluid  will  be  withdrawn  at  the  earliest  possible 
moment  and  thus  injury  to  the  heart,  through  inserting  the  needle 
too  deeply,  will  be  avoided.  Usually  at  a  depth  of  i  inch  (2.5  cm.) 
the  pericardium  will  be  entered.  Care  must  be  taken  not  to  produce 
too  great  a  vacuum  in  the  aspirator  lest  the  fluid  be  withdrawn  too 
rapidly — it  should  simply  trickle  into  the  aspirator. 

As  soon  as  the  desired  quantity  is  removed,  the  aspirating  needle 



is  quickly  withdrawn,  and  the  seat  of  puncture  is  occluded  with 
cotton  and  collodion,  or  else  by  a  pad  of  sterile  gauze  held  in  place 
by  adhesive  plaster. 

Complications  and  Dangers. — It  should  be  remembered  that 
aspiration  of  the  pericardium  is  no  simple  procedure,  but  is  an  opera- 
tion attended  by  danger.  Infection  of  the  pericardium,  injury  to 
the  internal  mammary  vessels,  puncture  of  the  pleura,  and  lacera- 
tion of  the  coronary  artery  and  the  heart  itself  by  the  aspirating  needle 
have  all  been  observed.  Strict  attention  to  asepsis,  extreme  care 
in  introducing  the  aspirating  needle  or  trocar,  and  observance  of  the 
various  points  in  technic  that  have  been  emphasized  will  do  much  in 
preventing  such  accidents. 


Paracentesis  of  the  abdomen  consists  in  puncturing  the  perit- 
oneal cavity  by  means  of  a  trocar  and  cannula  and  withdrawing  the 
fluid  therein  contained.  It  is  an  operation  attended  by  practically 
no  risks  and  can  safely  be  repeated  many  times  in  the  same  individual 
when  necessary. 

Indications. — The  abdomen  may  be  aspirated  in  cases  of  ascites 
when  the  physical  signs  show  the  presence  of  fluid,  and  distention 

Fig.   297. — Trocar  and  cannula  for  aspirating  the  peritoneal  cavity,      i,   Trocar 
and  cannula  assembled;  2,  showing  trocar  removed  from  the  cannula. 

becomes  distressing  from  pressure  upward  upon  the  diaphragm.  It 
should  also  be  performed  when  the  fluid  reaccumulates  after  a 
previous  tapping  and  gives  rise  to  pressure  symptoms. 

Instruments,  Etc. — A  straight  or  slightly  curved  cannula  and 
trocar  of  fair  size— about  1/16  to  1/8  inch  (1.5  to  3  mm.)  in  diameter 
— should  be  used.  The  trocar  is  spear-pointed  and  should  lit  the 
cannula  perfectly  so  as  to  prevent  the  point  of  the  latter  catching 
in  the  tissues  during  its  introduction  (Fig.  297) .     An  excellent  form  of 



cannula,  and  one  frequently  used,  contains  a  lateral  opening  about 
1/8  inch  (3  mm.)  from  its  end,  for  the  purpose  of  avoiding  stoppage 
of  the  escaping  fluid,  should  the  intestines  or  omentum  obstruct 
the  end  opening  of  the  instrument. 

If  desired,  the  aspirating  apparatus  of  Potain  or  Dieulafoy  (page 
286)  may  be  used  in  place  of  the  simple  trocar. 

In  addition  a  scalpel  to  make  a  small  preliminary  incision,  a 
sterile  abdominal  binder,  a  many-tailed  bandage  or  large  towel,  and 
collodion  and  cotton  or  sterile  gauze  and  adhesive  plaster  for  the 
dressing  should  be  provided. 

Fig.   298. — Sites  for  aspiration  of  the  peritoneal  cavity. 

Site  of  Puncture. — The  selection  of  a  location  free  from  vessels 
and  where  the  abdominal  wall  is  thin  is  desirable.  Usually  a 
point  in  the  linea  alba  midway  between  the  umbilicus  and  pubes  is 
selected,  but  the  puncture  may  be  at  a  point  in  the  linea  semilu- 
naris just  outside  the  rectus  muscle  at  the  junction  of  the  outer  and 
middle  thirds  of  a  line  between  the  umbilicus  and  the  anterior  supe- 
rior iliac  spine  (Fig.  298).  A  puncture  at  either  of  these  sites  will 
avoid  the  deep  epigastric  vessels.  Should  repeated  punctures  be 
made,  it  will  be  of  advantage  to  change  the  site  a  little  each  time  so  as 
to  avoid  entering  adhesions  which  may  have  been  produced  by  a 
previous  puncture. 



Quantity  Withdrawn. — Whether  all  the  fluid  should  be  removed 
at  once  will  be  determined  by  the  condition  of  the  patient  and  the 
manner  in  which  he  bears  the  operation.  As  a  general  thing  there  is 
no  harm  in  removing  all  the  fluid,  provided  it  is  not  evacuated  too 

Position  of  Patient. — The  patient  should  sit  upright  on  the  edge 
of  the  bed,  if  possible,  or,  if  unable  to  do  this,  he  may  lie  propped  up 
in  a  semirecumbent  position  so  as  to  favor  gravitation  of  the  fluid  to 

Fig.  299. — Aspiration  of  the  peritoneal  cavity.     First  step,  application  of  the 
*  abdominal  binder. 

the  lowest  level  of  the  peritoneal  cavity.  When  the  puncture  is  made 
in  the  linea  semilunaris,  the  patient  should  lie  upon  the  side  on  which 
the  puncture  is  made. 

Preparations. — Tlie  bladder  and  bowels  should  always  be  empty 
before  operation.  The  abdominal  wall  is  shaved  and  the  site  of  punc- 
ture is  painted  with  tincture  of  iodin.  The  operator's  hands  should 
likewise  be  sterilized,  and  the  trocar  is  to  be  boiled. 

Anesthesia. — Local  anesthesia  with  ethyl  chlorid,  ether,  ice  and 
salt,  or  infiltration  with  a  few  drops  of  a  0.2  per  cent,  solution  of 
cocain  or  a  i  per  cent,  solution  of  novocain  may  be  used. 

Technic. — A  broad  abdominal  binder,  or  a  Scultetus  bandage 
with  a  central  slit  corresponding  to  the  point  where  the  trocar  is  to  be 
introduced,  is  first  fitted  about  the  patient's  abdomen  (Fig.  299)  and 



is  to  be  tightened  at  intervals  during  the  operation,  so  that  uniform 
pressure  may  be  appKed  while  the  fluid  is  flowing  off  and  a  sudden 
overfilling  of  the  abdominal  vessels  with  blood  prevented.  With  a 
scalpel  the  skin  is  incised  for  a  distance  of  1/4  inch  (6  mm.)  at  the 
spot  chosen  for  the  puncture  (Fig.  300),  and  the  trocar  is  slowly  and 
steadily  inserted,  with  the  index  finger  held  along  the  instrument  as 
a  guide  to  the  depth  it  is  to  enter,  and  to  prevent  it  from  being  sud- 
denly forced  in  too  far  (Fig.  301).  As  soon  as  it  is  judged  that  the 
peritoneal  cavity  has  been  reached,  the  trocar  is  withdrawn  and  the 
fluid  is  permitted  to  escape. 

Fig.  300. — Aspiration  of  the  peritoneal  cavity.     Second  step,  nicking  the  skin  at 

the  point  of  puncture. 

The  fluid  should  be  evacuated  slowly,  and,  if  it  flows  too  freely, 
it  is  well  to  stop  the  flow  at  intervals  by  placing  the  finger  over  the 
end  of  the  trocar,  in  order  to  allow  the  abdominal  contents  to  adapt 
themselves  to  the  changed  conditions.  If  the  stream  is  suddenly 
stopped  by  the  intestines  or  omentum  occluding  the  end  of  the  instru- 
ment, a  slight  turn  of  the  cannula  or  a  change  in  its  position  may  be 
suf&cient  to  reheve  the  obstruction;  if  not,  it  may  be  necessary  to 
clear  the  lumen  by  passing  a  sterile  probe  through  it.  As  the  fluid 
is  withdrawn,  and  the  distention  of  the  abdomen  decreases,  neces- 
sary support  is  given  to  the  lax  abdominal  walls  by  drawing  the 
binder  tighter.     Syncope  may  be  thus  avoided;  should  it  occur,  how- 



ever,  the  escape  of  the  fluid  must  be  temporarily  stopped  by  placing 
the  finger  over  the  end  of  the  trocar  and  the  patient's  head  must  be 
lowered,  care  being  taken  to  see  that  air  does  not  enter  the  trocar 
while  this  is  being  done. 

When  fluid  ceases  to  flow,  the  cannula  is  quickly  removed  and, 
if  a  large  opening  has  been  made  by  the  trocar,  the  skin  may  be 
drawn  together  by  a  subcutaneous  stitch  and  the  line  of  incision 
sealed  with  collodion  and  cotton.  If  there  seems  to  be  a  good  deal 
of  oozing  of  fluid  along  the  track  of  the  trocar,  however,  a  sterile 

Fig.  301. — Aspiration  of  the  peritoneal  cavitj'-.     Third  step,  showing  the  method  of 

inserting  the  trocar. 

gauze  dressing,  held  in  place  with  rubber  adhesive  plaster  and 
changed  as  often  as  necessary,  will  be  found  more  satisfactory. 
After  the  aspiration  the  patient  should  be  kept  in  bed  for  at  least 
twenty-four  hours. 


This  operation  is  employed  for  the  cure  of  hydrocele.  It  consists 
in  introducing  an  aspirating  needle  or  trocar  and  cannula  into  the 
tunica  vaginalis  and  removing  the  contained  fluid.  It  may  be  per- 
formed simply  to  withdraw  the  hydrocitic  fluid  or  as  part  of  the 
radical  cure  by  injection  of  carbohc  acid.  The  former  is  rarely  more 
than  a  palliative  measure,  as  the  fluid  usually  promptly  recurs. 



The  treatment  by  a  combination  of  aspiration  and  the  injection 
of  95  per  cent,  carbolic  acid  is,  however,  successful  in  more  than  80 
per  cent,  of  cases  (Bevan).  It  is  especially  applicable  to  hydroceles 
with  thin  sacs;  in  the  old,  chronic  cases  with  thick  sacs  it  is  not  often 

The  operation  is  practically  without  danger,  if  performed  with 
proper  technic  and  care  is  taken  to  prevent  injury  to  the  structures 

Fig.  302. — Trocar  and  syringe  for  aspirating  and  injecting  a  hydrocele. 

of  the  cord  and  the  testicle.  The  latter  usually  lies  posterior  to 
the  tumor,  though  in  rare  cases  it  may  be  in  front.  Its  position 
should  always  be  ascertained  first,  if  possible,  by  palpation  and 

Instruments. — A  medium  size  trocar  and  cannula,  or  a  large 
aspirating  needle,  to  which  may  be  attached  a  small  aspirating 
syringe,  will  be  required  (Fig.  302). 

Pig.  303. — Aspirating  a  hydrocele.     Showing  the  method  of  grasping  the  scrotum 
and  the  trocar  being  inserted. 

Site  of  Puncture. — The  trocar  should  be  introduced  at  the  junc- 
tion of  the  lower  and  middle  thirds  of  the  anterior  surface  of  the 
scrotum,  at  a  spot  where  visible  blood-vessels  are  scarce. 

Asepsis. — The  usual  aseptic  precautions  should  be  observed. 
The  skin  at  the  site  of  puncture  should  be  shaved  and  then  painted 



with  tincture  of  iodin.     The  operator's  hands  should  be  prepared 
as  for  any  operation,  and  the  instruments  boiled. 

Anesthesia. — The  spot  of  intended  puncture  may  be  anesthetized 

Fig.  304. — Aspirating  a  hydrocele.     Showing  the  cannula  in  place. 

by  the  injection  of  a  few  drops  of  a  0.2  per  cent,  solution  of  cocain 
or  a  I  per  cent,  solution  of  novocain,  or  frozen  by  ethyl  chlorid. 

Technic. — The  operator  places  his  left  hand  behind  the  scrotum 

Fig.  305. — Method  of  injecting  a  hydrocele. 

and  grasps  the  neck  of  the  hydrocele  between  the  thumb  and  fore- 
finger, thus  making  the  tumor  tense  by  compression.  Holding  the 
trocar  and  cannula  in  the  right  hand  with  the  index  finger  placed 


about  I  inch  (2.5  cm.)  from  its  tip  so  as  to  prevent  the  instrument 
being  introduced  too  deeply,  the  operator  thrusts  it  into  the  tunica 
vaginaHs  in  an  upward  and  backward  direction  (Fig.  303).  As  soon 
as  the  trocar  enters  the  sac,  indicated  by  a  lack  of  resistance  to  its 
further  progress,  the  point  of  the  instrument  is  turned  upward  thus 
depressing  the  free  end  and  the  trocar  is  removed  (Fig.  304).  All  the 
fluid  is  then  allowed  to  escape,  and,  to  make  sure  the  sac  is  empty, 
the  aspirator  may  be  attached  and  suction  employed. 

The  cannula  is  left  in  site  and  from  5  to  30  drops  (0.3  to  2  c.c.) 
of  95  per  cent,  (deliquescent)  carbolic  acid,  depending  upon  the  size 
of  the  hydrocele,  are  injected  through  the  cannula  (Fig.  305).  If  a 
syringe  cannot  be  attached  directly  to  the  cannula,  the  injection  may 
be  made  by  means  of  a  hypodermic  syringe  and  a  long  needle  in- 
serted through  the  cannula.  The  skin  is  then  pinched  up  around  the 
cannula,  which  is  quickly  removed,  and  the  scrotum  is  manipulated 
so  as  to  smear  the  acid  over  the  whole  interior.  The  puncture  is 
then  finally  sealed  with  collodion  and  cotton. 

The  patient  should  remain  in  bed  twenty-four  to  forty-eight  hours 
after  the  operation  with  a  supporting  dressing  applied  to  the  scrotum. 
Some  swelling  follows  the  injection,  but  it  usually  subsides  within  a 
week  or  ten  days.  During  this  time  the  patient  should  wear  a 
well-fitting  suspensory. 


Aspiration  of  the  bladder  will  be  considered  under  the  section 
devoted  to  that  organ  (see  page  692). 


Anatomic  Considerations 

The  Nose. — For  purposes  of  description  the  nose  is  divided  into 
an  external  and  an  internal  portion. 

The  external  nose  forms  a  prominence  upon  the  face  resembling  a 
triangular  pyramid,  made  up  chiefly  of  bone  and  cartilage  and 
covered  with  muscles  and  integument.  The  bony  portion,  or  bridge, 
is  composed  of  the  nasal  portions  of  the  superior  maxilla  and  the  two 
nasal  bones.  The  arch  forming  the  forepart  of  each  side  of  the  nose 
is  composed  of  two  large  lateral  cartilages  which  converge  to  form  the 
ridge  and  tip.  These  are  supplemented  usually  by  three  smaller 
cartilages  bound  together  by  connective  tissue,  which  aid  in  forming 
the  wings  or  alae. 

The  interior  of  the  nose  is  divided  by  the  septum  into  two  cham- 
bers, or  fossae,  narrow  above  and  more  expanded  below.  These 
open  anteriorly  by  the  anterior  nares,  two  pear-shaped  apertures 
measuring  about  i  inch  (2.5  cm.)  vertically  and  1/2  inch  (i  cm.) 
transversely  at  their  widest  points.  Posteriorly,  the  nasal  fossae 
communicate  with  the  nasopharynx  by  two  corresponding  openings, 
the  posterior  nares.  Each  fossa  also  communicates  with  air  spaces 
situated  in  the  frontal,  ethmoid,  sphenoid,  and  superior  maxillary 
bones.  The  roof  is  formed  by  the  nasal  bones,  the  cribriform  plate 
of  the  ethmoid,  and  the  body  of  the  sphenoid.  The  floor,  concave 
from  side  to  side,  is  formed  by  the  palatal  process  of  the  superior 
maxilla  and  the  horizontal  process  of  the  palate  bones.  It  separates 
the  nose  from  the  mouth.  The  inner  wall,  or  septum,  is  formed 
posteriorly  by  the  perpendicular  plate  of  the  ethmoid  and  the  vomer, 
and  anteriorly  by  the  triangular  cartilage.  The  septum  is  seldom 
exactly  in  the  median  line,  but  is  usually  more  or  less  deflected,  so 
that  it  is  unusual  to  find  the  two  fossae  of  equal  size.  The  outer  walls 
of  the  nose  are  formed  by  the  superior  maxillary,  the  lachrymal,  the 
ethmoid,  the  palate,  and  the  sphenoid  bones.  They  are  very  irreg- 
ular, due  to  the  presence  of  the  turbinate  bodies  which  project  into 
the  fossae  and  partly  divide  them  into  three  separate  recesses,  the 
superior,  the  middle,  and  the  inferior  meatus  (Fig.  306). 




The  superior  meatus  lies  between  the  superior  and  middle  turbi- 
nates. It  is  narrow  and  groove-like,  and  is  the  smallest  of  the  three. 
The  orifices  of  the  posterior  ethmoidal  cells  open  upon  the  upper  and 
forepart  of  its  outer  wall. 

Fig.  306 — Transverse  section  of  the  nasal  cavities.     (After  Zuckerkandl.) 

The  middle  meatus  lies  between  the  middle  and  inferior  turbinates, 
and  is  more  capacious  than  the  superior,  extending  along  the  pos- 
terior two-thirds  of  the  outer  wall  of  the  nose.  Opening  into  the 
middle  meatus  on  the  outer  wall  is  a  crescentic  slit-like  aperture, 

Fig.  307. — Showing  the  structures  in  the  outer  wall  of  the  nasal  cavity.  1, 
Opening  of  the  sphenoidal  sinus;  2,  superior  meatus;  3,  middle  meatus;  4,  inferior 

the  hiatus  semilunaris.  Just  above  it,  and  at  times  partly  occluding 
this  opening,  is  a  protuberance,  the  bulla  ethmoidalis,  which  marks 
the  situation  of  the  anterior  ethmoidal  cells.  Upon  the  lateral  wall  of 
the  middle  meatus  and  extending  from  the  hiatus  semilunaris  upward 



and  forward,  is  a  curved  groove  bounded  internally  by  the  uncinate 
process  of  the  ethmoid,  known  as  the  infundibulum.  From  this  a 
closed  duct  leads  into  the  frontal  sinus.  At  the  deepest  portion  of 
the  infundibulum  near  the  posterior  end,  is  the  opening  of  the  max- 
illary sinus,  and  behind  this  at  times  is  found  an  accessory  opening. 
The  anterior  ethmoidal  cells  also  open  into  the  infundibulum  on  the 
upper  part  of  the  outer  wall  or  else  they  communicate  with  the 
frontonasal  duct. 

From  the  anatomical  relation  of  these  openings,  it  can  be  under 
stood  how  readily  infection  of  the  maxillary  sinus  may  follow  a  sup- 
purative condition  of  the  anterior  ethmoidal  cells  or  frontal  sinus 

Fig.  308. — Lateral  wall  of  the  right  nasal  cavity  showing  the  orifices  of  the 
accessory  sinuses.  (After  Schultze  and  Stewart.)  The  dotted  line  indicates  the 
outline  of  the  Aiiddle  turbinate,  which  has  been  removed  to  show  the  structures 
beneath.  A  portion  of  the  inferior  turbinate  has  also  been  removed,  i,  Frontal 
sinus;  2,  infundibulum;  3,  hiatus  semilunaris;  4,  orifice  of  the  nasal  duct;  5,  bulla 
ethmoidalis;  6,  inferior  turbinate;  7,  accessory  orifice  of  the  maxillary  sinus;  8, 
orifice  of  Eustachian  tube;  9,  fossa  of  Rosenmiiller;  10,  sphenoidal  sinus;  11, 
orifice  of  the  sphenoidal  sinus;  12,  orifice  of  the  middle  and  posterior  ethmoidal 
cells;   13,  orifice  of  the  anterior  ethmoidal  cells. 

discharges  from  the  latter  being  very  apt  to  find  their  way  into  the 
ostium  of  the  maxillary  sinus. 

The  inferior  meatus,  the  largest  of  the  three,  lies  between  the 
inferior  turbinate  bone  and  the  floor  of  the  nasal  cavity,  extending 
along  the  entire  length  of  the  outer  wall  of  the  nose.  The  nasal  duct, 
leading  from  the  orbit,  opens  into  the  inferior  meatus  at  the  junction 
of  the  anterior  third  with  the  posterior  two-thirds. 

The  mucous  membrane  lining  the  nasal  cavity  is  continuous 
anteriorly  with  the  integument  and  also  with  the  mucous  membrane 
of  the  pharynx,  Eustachian  tubes,  and  accessory  sinuses.     In  the 



upper  portion  of  the  nose  the  mucous  membrane  is  of  the  columnar 
variety.  In  this  region  it  is  thin  and  closely  bound  to  the  perios- 
teum and  perichondrium  beneath,  and  contains  the  endings  of  the 
olfactory  nerves.  The  remainder  of  the  nasal  cavity  is  lined  with 
ciliated  epithelium.  Over  the  inferior  turbinates,  the  lower  portion 
of  the  middle  turbinates,  and  corresponding  parts  of  the  septum  the 
mucous  membrane  is  thick  and  very  vascular,  containing  numerous 
thin-walled  venous  channels  capable  of  becoming  so  enormously  dis- 
tended with  blood  that  they  may  even  occlude  the  nares.  On  the 
floor  of  the  nose  the  mucous  membrane  again  becomes  thinned  out. 
The  Accessory  Sinuses.— Hollowed  out  of  the  bones  surround- 
ing the  nasal  foss£e  are  four  cavities  filled  with  air,  known  as  the 
maxillary,  frontal,  ethmoid,  and  sphenoid  sinuses.     These  accessory 

Fig.  309. — Cross-section  of  the  maxillary  sinuses,  showing  the  close  relation  of  the 
roots  of  the  molar  teeth  to  the  floors  of  the  sinuses.      (After  Zuckerkandl.) 

sinuses  are  lined  with  a  thin,  pale,  mucous  membrane  continuous 
with  that  of  the  meatus  into  which  each  sinus  respectively  opens. 
The  function  of  the  sinuses  is  to  give  resonance  to  the  voice  and  at 
the  same  time  add  to  the  lightness  of  the  skull. 

The  maxillary  sinus  or  antrum  of  Highmore,  lies  to  the  outer  side 
of  the  nasal  fossa,  occupying  the  greater  portion  of  the  superior  max- 
illary bone.  It  is  the  largest  of  all  the  accessory  sinuses.  In  shape 
it  resembles  a  three-sided  pyramid,  with  the  apex  at  the  zygomatic 
process  of  the  maxilla,  and  the  base  directed  toward  the  nasal  cavity. 
The  roof  of  the  antrum  is  very  thin  and  forms  the  floor  of  the  orbit. 
The  anterior  wafl  is  directed  toward  the  face  and  corresponds  to  the 
canine  fossa  externally.  The  floor,  which  is  directed  toward  the 
mouth,  is  formed  by  the  alveolar  margin  and  outer  portion  of  the  hard 


palate.  The  roots  of  the  molar  teeth  almost  protrude  through  the 
floor  into  the  antrum  (Fig.  309),  being  often  separated  from  the  cavity 
by  a  thin  shell  of  bone,  or  merely  mucous  membrane,  so  that  ulcera- 
tion of  the  teeth  may  readily  lead  to  infection  of  the  sinus.  This 
anatomical  arrangement  is  sometimes  taken  advantage  of  in  draining 
the  antrum,  a  tooth  being  extracted  and  the  sinus  opened  through 
the  alveolus. 

Ordinarily,  the  antrum  has  a  capacity  of  about  4  drams  (15  c.c), 
but  its  size  varies  greatly,  and  in  the  same  individual  the  two  sides 
are  frequently  disproportionate.  The  antrum  communicates  with  the 
middle  meatus  by  an  ostium  opening  into  the  infundibulum,  and 
thence  through  the  hiatus  semilunaris.  This  aperture  cannot  be 
seen  until  the  middle  turbinate  has  been  removed.  In  a  small  per- 
centage of  cases  an  accessory  ostium  is  found  lying  posterior  to  the 
main  opening. 

The  Frontal  Sinus. — The  frontal  sinuses  are  two  air  spaces  sepa- 
rated from  each  other  by  a  septum,  lying  between  the  tables  of  the 
frontal  bone  above  the  orbits.  Each  consists  of  a  vertical  portion 
passing  upward  on  the  forehead  and  a  horizontal  portion  extending 
backward  over  the  roof  of  the  orbit.  Their  size  is  variable  and  they 
are  often  unequal  through  deflection  of  the  septum  to  one  side. 
Cases  have  been  observed  with  one  sinus  entirely  absent.  The  floor 
of  the  sinus  forms  by  its  external  portion  the  roof  of  the  orbit,  and  by 
its  inner  portion  the  roof  of  some  of  the  anterior  ethmoidal  cells. 
The  latter  part  of  the  floor  is  extremely  thin,  so  that  suppuration  of 
the  frontal  sinus  is  liable  to  extend  to  the  anterior  ethmoidal  cells. 
The  posterior  wall  separates  the  sinus  from  the  frontal  lobes  of  the 
brain  by  an  extremely  thin  plate  of  bone.  The  anterior  wall  is  thick 
and  is  represented  externally  by  the  superciliary  ridge.  In  the 
posterior  portion  of  the  floor  of  the  sinus  is  the  rounded  or  oval 
aperture  leading  into  the  infundibulum  and  thence  to  the  middle 
meatus  by  means  of  the  hiatus  semilunaris. 

The  ethmoidal  cells  lie  in  the  lateral  masses  of  the  ethmoid  bone. 
These  cells  vary  in  size  and  number.  They  are  divided  into  two 
sets,  anterior  and  posterior.  The  anterior  open  into  the  middle 
meatus,  generally  by  the  infundibulum,  while  the  posterior  set 
open  into  the  superior  meatus.  These  cells  are  separated  from  the 
cranial  cavity  and  orbit  by  extremely  thin  plates  of  bone. 

The  sphenoidal  cells  are  situated  in  the  body  of  the  sphenoid  bone 
close  to  the  base  of  the  skull.  They  are  quadrilateral  in  shape  and 
variable  in  size,  and,  like  the  frontal  sinuses,  they  may  be  asymmetri- 


cal  from  deviation  of  the  septum.  The  anterior  wall  looks  downward 
and  forward  and  forms  a  part  of  the  roof  of  the  nasal  cavity.  The 
upper  wall  is  very  thin  and  separates  the  sinus  from  the  cranial 
cavity.  The  cells  communicate  with  the  nasal  cavity  through  an 
opening  situated  above  and  behind  the  superior  turbinate. 

Diagnostic  Methods 

Prior  to  making  an  internal  examination  of  the  nasal  cavities, 
careful  notes  should  be  taken  of  the  patient's  history  and  symptoms, 
for  future  reference,  and  a  thorough  inspection  should  be  made  of  the 
external  nose.  On  general  inspection  one  should  note  the  shape  of 
the  nose,  with  reference  to  signs  of  cretinism,  s^^hilis.  new  growths, 
deviations,  or  deformities.  The  shape  of  the  jaws  also  should  be 
observed;  likewise  the  presence  or  absence  of  any  prominences  or 
bulging  in  the  neighborhood  of  the  accessory  sinuses;  the  presence  or 
absence  of  enlarged  cervical  glands;  the  presence  of  excoriations, 
herpes,  or  crusts  about  the  anterior  nares  and  upper  lip,  as  indica- 
tions of  nasal  discharge.  It  should  be  ascertained  whether  the  patient 
breathes  through  the  mouth,  and  the  patency  of  the  nose  should  be 
tested  by  alternately  closing  each  nostril  with  the  finger  while  the 
patient  breathes  through  the  opposite  one.  The  odor  of  the  breath, 
the  presence  or  absence  of  marked  movement  of  the  al^  nasi,  or  any 
sounds  produced  during  nasal  breathing,  and  the  character  of  the 
voice  should  also  be  carefully  noted.  Having  completed  this  pre- 
liminary examination,  that  of  the  interior  of  the  nose  may  be  pro- 
ceeded with. 

For  an  examination  of  the  nasal  caA^ty  and  accessory  sinuses 
five  methods  are  available:  namely,  (i)  inspection  or  rhinoscopy; 
(2)  probing;  (3)  palpation;  (4)  transillumination;  and  (5)  skiagraphy. 


Inspection  of  the  interior  of  the  nose  may  be  performed  by 
anterior  and  by  posterior  rhinoscopy.  In  anterior  rhinoscopy  the 
examination  is  made  through  the  anterior  nares  with  the  aid  of  a 
suitable  speculum  and  a  strong  light.  Posterior  rhinoscopy  consists 
in  an  examination  of  the  nose  from  within  the  pharynx  by  the  aid 
of  reflected  light  and  a  rhinoscopic  or  small  laryngeal  mirror.  The 
former  is  simple  and  requires  no  great  skill,  but  the  latter  is  by  no 
means  an  easy  procedure  for  one  not  specially  trained,  and  at  times 



requires  considerable  patience  on  the  part  of  the  operator  to  com- 
plete successfully  and  satisfactorily. 

Illumination. — To  obtain  a  satisfactory  view  of  the  interior  of  the 
nose,  it  is  necessary  to  have  good  illumination.  Strong  sunlight 
may  be  utilized  for  anterior  rhinoscopy,  but  it  is  not  suitable  for  an 
examination  of  the  posterior  nares.  A  Welsbach  burner  fitted  with  a 
mica  chimney  over  which  is  placed  a  Mackenzie  condenser  gives 
excellent  illumination  (Fig.  310).  Electric  light  from  a  frosted 
lamp  is  also  much  used  and  has  an  advantage  in  that  it  does  not 
give  out  much  heat. 

Fig.  310. — Gas  lamp  upon  an  adjustable  stand  fitted  with  a  Mackenzie  condenser. 

Whatever  the  form  of  light,  it  should  be  so  arranged  upon  a 
suitable  bracket  that  it  may  be  raised,  lowered,  or  turned  from  side 
to  side  without  inconvenience  to  the  operator.  The  light  should  be 
placed  upon  the  patient's  right,  somewhat  behind  him,  and  about 
on  a  level  with  the  tip  of  his  ear. 

Many  operators  prefer  an  illumination  furnished  by  an  electrical 
head  light  (Fig.  311).  Such  a  light,  with  the  current  furnished  from 
a  small  pocket  storage  battery  will  be  found  a  great  convenience 
outside  the  examining  room. 



Instruments.— In  addition  to  a  suitable  light,  there  will  be  re- 
quired: a  concave  head  mirror,  about  3  1/2  to  4  inches  (9  to  10  cm.) 
in  diameter,  with  a  large  central  eye-hole,  and  secured  to  a  soft 
leather  headband  by  a  bah-and-socket  joint;  a  rhinoscopic  mirror 

Fig.  311. — Electric  head  light. 

YiG,  312.— Instruments  for  rhinoscopy,  i,  Alcohol  lamp;  2,  rhinoscopic 
mirror;  3,  White's  palate  retractor;  4,  Myles'  nasal  speculum;  5,  head  mirror; 
6,  nasal  appUcator;  7,  Fraenkel's  tongue  depressor. 

1/2  inch  (i  cm.j  m  diameter,  set  at  an  angle  of  100  to  no  degrees 
with  the  shaft,  which  is  curved  to  follow  the  Hne  of  the  tongue;  a 
Myles  soUd-blade  nasal  speculum;  a  Fraenkel  tongue  depressor;  a 
White  palate  retractor;  and  a  nasal  appKcator  with  a  triangular- 
tipped  shaft  (Fig.  312). 



Asepsis. — Instruments,  such  as  tongue  depressors,  specula, 
applicators,  etc.,  may  be  sterilized  by  boiling.  The  rhinoscopic 
mirrors,  however,  which  are  soon  destroyed  by  boiling,  may  be 
sterilized  by  immersion  in  a  solution  of  i  to  20  carbolic  acid  and 
then  wiped  dry  before  using. 

Position  of  the  Patient. — The  patient  is  seated  upright  upon  a 
firm,  straight-backed  chair.  The  examiner  sits,  facing  the  patient, 
upon  an  adjustable  seat,  such  as  a  piano  stool,  which  may  be  readih- 
raised  or  lowered  according  to  the  height  of  the  patient. 

Technic. — i.  Anterior  Rhinoscopy. — The  operator  adjusts  the 
head  mirror  in  such  a  way  that  the  central  opening  is  opposite  his 
left  eye  and  the  light  is  reflected  into  the  nostrils  of  the  patient.  The 
outline  of  the  anterior  nares  is  then  brought  into  view,  and  the 
relative  size  of  the  two  fossae  may  be  appreciated.  Care  should  be 
taken  to  look  for  fissures,  abrasions,  or  pimples  on  the  inner  surface 

Fig.  313. — Myles'  speculum  in  place. 

of  the  vestibule  of  the  nose,  contact  with  which  would  make  the  in- 
troduction of  the  speculum  painful,  without  preliminary  cocainiza- 
tion.  The  speculum  is  then  introduced  with  the  blades  closed,  and, 
upon  sliding  them  apart,  the  necessary  amount  of  dilatation  is  ob- 
tained (Fig.  313). 

The  inspection  of  the  cavity  should  proceed  from  before  backward, 
the  Ught  being  thrown  into  all  recesses.  By  slightly  elevating  the 
tip  of  the  nose,  the  floor  of  the  nose,  the  inferior  turbinate,  and  the 
inferior  meatus  are  brought  to  view.  In  some  cases  where  the  nose 
is  very  broad  or  the  inferior  turbinate  small  or  shrunken,  it  may  even 
be  possible  to  see  as  far  back  as  the  posterior  wall  of  the  nasopharynx. 
By  bending  the  patient's  head  backward  and  raising  the  chin,  the 



middle  meatus  and  the  middle  turbinate  may  be  seen;  only  when  the 
latter  has  been  removed,  or  is  very  much  atrophied,  however,  is  it 
possible  to  obtain  a  view  of  the  apertures  leading  to  the  accessory 
sinuses.  Tilting  the  patient's  head  still  further  backward  exposes 
to  view  the  upper  portion  of  the  middle  turbinate  and  the  roof  of  the 
nose.  Occasionally  the  opening  of  the  sphenoidal  sinus  may  be 
made  out,  but  only  in  exceptional  cases  is  it  possible  to  see  the 
superior  turbinate. 

By  the  direct  application  of  cocain  or  adrenalin  to  the  mucous 
membrane  with  cotton  pledgets  or  by  spraying,  the  membrane  may 

Fig.  314. — Showing  the  method  of  performing  anterior  rhinoscopy. 

be  caused  to  shrink  and  a  more  satisfactory  view  of  the  structures 
within  the  nose  may  be  obtained.  This  is  especially  useful  where  the 
nasal  cavity  is  narrow  or  the  turbinates  are  hypertrophied. 

Secretions  that  obstruct  the  view  are  gently  wiped  away  by 
means  of  a  cotton-wrapped  nasal  probe  or  applicator.  The  appear- 
ance and  general  condition  of  the  mucous  membrane  are  thus  in- 
spected and  the  apparent  source  of  any  discharge  noted.  In  general, 
pus  in  the  middle  meatus  means  that  the  frontal  or  maxillary  sinus 
or  anterior  ethmoidal  cells  are  involved,  as  they  all  drain  into  this 
recess;  while  a  discharge  seen  in  the  space  between  the  middle  tur- 
binate and  septum  signifies  infection  of  either  the  sphenoidal  or  pos- 



terior  ethmoidal  cells.  To  ascertain  exactly  which  sinus  is  involved, 
frequently  other  aids  to  diagnosis,  as  probing,  transillumination,  or 
skiagraphy,  must  be  employed. 

The  attention  of  the  examiner  is  fmally  directed  to  the  bony  and 
cartilaginous  portions  of  the  nose.  Deviations,  ulcerations,  perfora- 
tions, and  spurs  of  the  septum,  contracture  or  hypertrophy  of  the 
turbinal  bodies,  the  presence  of  foreign  bodies,  the  presence  of  new 
growths  and  their  point  of  attachment,  etc.,  etc.,  are  in  a  general 
way  the  conditions  to  be  looked  for. 

2.  Posterior  Rhinoscopy. — The  operator  adjusts  the  head  mirror 
over  his  left  eye  so  that  the  light  is  thrown  upon  the  patient's  mouth. 
The  patient  is  instructed  to  open  the  mouth,  and  a  tongue  depressor 

Fig.  315. — First  step  in  posterior  rhinoscopy,  inserting  the  tongue  depressor 

held  between  the  thumb  and  the  index  and  middle  fingers  of  the  left 
hand,  is  inserted  and  passed  over  the  dorsum  of  the  tongue  until  the 
tip  of  the  instrument  rests  just  behind  its  arch.  The  tongue  is  then 
drawn  downward  and  forward  into  the  floor  of  the  mouth  (Fig. 
315).  If  care  be  taken  not  to  insert  the  depressor  too  far  and  to  avoid 
pushing  back  on  the  tongue,  gagging  will  be  prevented.  A  mirror  of 
suitable  size  is  then  warmed  and,  with  the  light  reflected  upon  the 
posterior  pharyngeal  wall,  the  mirror  is  gently  introduced  into  the 



mouth,  lightly  held  between  the  thumb  and  forefinger  of  the  right 
hand  with  its  metal  surface  directed  toward  the  tongue.  The  mirror 
should  then  be  carefully  carried  back  into  the  nasopharynx,  avoiding 
the  back  of  the  tongue,  the  palate,  and  uvula.  After  the  instru- 
ment has  entered  the  nasopharyngeal  space,  a  clear  view  of  the  pos- 
terior ends  of  the  turbinates  and  the  other  postnasal  structures  will 
be  obtained  by  depressing  the  handle  of  the  instrument  sHghtly  so 
that  the  upper  border  of  the  mirror  lies  behind  the  soft  palate.  At 
the  same  time,  the  handle  of  the  mirror  should  be  so  held  toward 
the  left  angle  of  the  patient's  mouth  that  illumination  is  not  interfered 
with  (Fig.  316). 

Fig.  316. 

Fig.  317. 

Fig.  316. — Showing  the  rhinoscopic  mirror  in  place. 

Fig.  317. — Posterior  rhinoscopic  image,  i,  Roof  of  pharynx;  2  uvula;  3 
soft  palate;  4,  opening  of  Eustachian  tube;  5,  superior  turbinate;  6,  middle  tur- 
binate; 7,  inferior  turbinate. 

It  should  be  remembered  that  it  is  not  possible  to  obtain  a  view  of 
the  whole  postnasal  space  at  one  time,  but,  on  turning  the  mirror  in 
various  directions  by  rotating  its  handle,  different  portions  may  be 
brought  into  view  and  the  entire  space  may  thus  be  examined  in 
detail.  By  first  holding  the  handle  of  the  instrument  well  up,  the 
vault  of  the  pharynx  will  be  brought  into  view,  and  the  presence  or 
absence  of  adenoids  or  other  tumors  may  be  ascertained.  The 
pharyngeal  vault  is  usually  smooth  and  dome-shaped,  but  it  may  be 
almost  completely  filled  up  and  show  depressions  and  elevations 
depending  on  the  size  and  condition  of  the  pharyngeal  tonsil.  On 
depressing  the  handle  slowly,  the  posterior  nares  may  be  examined 



in  detail  from  above  downward.  In  the  median  line  is  seen  the 
septum;  on  either  outer  wall  from  above  downward  will  be  seen  the 
ridge  of  the  superior  turbinate,  w4th  the  superior  meatus  lying  just 
below  as  a  darkened  depression.  Below  this  wdll  be  observed  the 
middle  turbinate  as  a  pinkish-white  fusiform  body,  and,  underlying 
this,  the  middle  meatus.  The  inferior  turbinate  appears  just  below 
this  as  a  grayish- white  body.  Finally,  by  turning  the  mirror  to  either 
side,  the  orifices  of  the  Eustachian  tubes  and  the  Eustachian  cushions 
are  brought  to  view.  Care  should  be  taken  not  to  keep  the  mirror 
in  the  throat  too  long  or  the  patient  will  be  tired  out;  to  make  a 
complete  examination,  it  is  better  to  reinsert  it  more  than  once  if 

Fig.  318. — White's  palate  retractor  in  place. 

In  some  cases  it  may  be  almost  an  impossibility  to  make  a  satisfac- 
tory posterior  rhinoscopic  examination.  This  may  be  from  the  forma- 
tion of  the  parts,  as,  for  example,  in  the  presence  of  a  hard  palate 
which  extends  so  far  back  that  there  is  no  room  for  the  mirror,  or  a 
broad  soft  palate  w^ith  a  long  uvula,  or  it  may  be  due  to  the  presence  of 
a  growth  in  the  nasopharynx.  The  most  common  obstacle,  however, 
is  the  involuntary  elevation  of  the  soft  palate  on  the  introduction  of 
the  mirror,  so  that  the  view  of  the  parts  above  is  blocked.  Instructing 
the  patient  to  breathe  through  the  nose  with  the  mouth  open,  or  to 
pronounce  "en"  with  strong  nasal  sound,  often  suffices  to  overcome 
this  impediment.     In  other  cases  it  will  be  necessary  to  use  a  palate 



retractor,  such  as  White's.  After  applying  cocain  to  the  soft  palate, 
the  wire  palate  loop  of  the  instrument  is  passed  behind  the  soft  palate 
and  the  stem  of  the  instrument  so  adjusted  as  to  draw  the  palate  well 
forward  into  the  desired  position.  The  instrument  is  maintained  in 
position  by  means  of  the  wire  loops  which  rest  wdthin  the  nose 
(Fig.  318). 


To  overcome  the  difficulties  encountered  in  examining  the  naso- 
pharynx with  a  rhinoscopic  mirror,  Hays  has  devised  an  instrument 
made  on  the  plan  of  an  indirect  view  cystoscope,  which  he  calls  the 
pharyngoscope.^  With  this  instrument,  the  use  of  which  requires 
none  of  the  skill  necessary  for  the  ordinary  posterior  rhinoscopic 

Fig.  319. — Hays'  phan'^ngoscope. 

examination,  it  is  possible  to  obtain  a  clear  picture  of  tne  nasopharynx, 
posterior  nares,  Eustachian  tubes,  as  well  as  the  larynx  without 
the  slightest  discomfort  to  the  patient.  Furthermore,  as  the  various 
structures  are  brought  to  view  they  may  be  inspected  in  a  very 
systematic  and  thorough  manner  and  with  the  avoidance  of  any  haste, 
as  the  instrument,  once  inserted,  may  be  left  in  place  anywhere  from 
five  to  twenty  minutes,  during  which  time  its  position  need  not  be 

Instruments. — All  that  is  required  is  the  pharyngoscope  and  a  six- 
dry-cell  battery.  The  instrument  is  made  in  the  form  of  a  tongue 
depressor,  the  horizontal  portion   of  which  is  flattened  in  its  inner 

-Harold   Hays,   in  the    Neiv    York   Medical  Journal,  April  19,   1909,  and  the 
-Laryngoscope,   Jnlj,    1909. 



two- thirds,  and  in  its  widest  part  measures  less  than  5/8  inch  (1.6  cm.) 
It  contains  a  central  tube  into  which  a  movable  telescope  fits  and  also 
two  wire  carriers.  At  the  distal  end  of  the  instrument  are  placed  two 
lamps,  one  on  each  side  of  the  telescope.  On  the  circumference  of  the 
eye-piece  of  the  telescope  is  a  small  metal  guide,  to  indicate  the  direc- 
tion in  which  the  lens  is  turned.  The  length  of  the  horizontal  portion 
including  the  telescope  is  about  8  inches  (20  cm.).  The  vertical 
portion  or  handle  of  the  instrument  contains  the  wires  which  carry 
the  current  to  the  lamps.  Near  its  upper  end  is  placed  a  switch  for 
turning  on  or  ofi"  the  current  (F-'g.  319). 

Asepsis. — The  instrument  must  be  thoroughly  sterilized  before 
use.     This  is  accomplished  by  means  of  formalin  vapor  or  by  immer- 

FiG.  320. — Showing   the   method   of   inserting   the   Hays'   pharyngoscope    (after 
Hays,  Am.  Jour.  Surg.,  Ma\%  1909). 

sion  in  a  I  to  20  carbolic  acid  solution  followed  by  rinsing  in  alcohol 
or  sterile  water.     It  will  not  stand  boiling. 

Anesthesia. — As  a  rule,  anesthesia  is  not  necessary.  Should, 
however,  gagging  be  induced  by  the  instrument,  the  posterior 
pharyngeal  wall  may  be  cocainized. 

Technic. — The  patient  is  instructed  to  open  his  mouth  widely 
and  breathe  quietly.  The  instrument  is  then  inserted  in  the  same 
manner  as  a  tongue  depressor,  until  its  distal  end  lies  about  1/16 
inch  (1.5  mm.)  from  the  pharyngeal  wall  (Fig.  320).  The  instru- 
ment is  kept  steadily  in  place  upon  the  tongue,  and  the  patient 
is  told  to  close  the  mouth  and  breathe  through  his  nose.     This 



produces  relaxation  and  consequent  widening  of  the  pharynx  and 
nasopharynx.  The  hght  is  then  turned  on,  and  the  examiner 
inspects  the  structures  as  they  are  separately  brought  to  view  by 
rotation  of  the  telescope.  Thus  with  the  lens  pointing  upward,  as 
shown  by  the  knob  on  the  eye-piece,  the  pharyngeal  vault  is  brought 
to  view,  and,  by  tilting  the  distal  end  of  the  instrument  slightly 
upward,  the  posterior  nares  are  viewed. 

To  inspect  the  region  of  the  Eustachian  tubes  the  lens  is  rotated 
to  about  30  degrees  to  one  side,  when  the  orifices  of  the  tubes,  Rosen- 
miiller's  fossa,  etc.,  will  be  clearly  shown.  By  rotating  the  lens  so 
that  it  points  downward  the  epiglottis,  larynx,  and  base  of  the  tongue 
are  similarly  inspected. 

Fig.  321. — Showing  the  pharyngoscope  in  place  with  the  examiner  inspecting  the 

postnasal  space. 


The  use  of  the  probe  is  essential  to  a  complete  examination  of  the 
nose.  By  its  aid  the  consistency  and  character  of  structures  normally 
present,  as  well  as  the  presence  of  abnormal  growths,  adhesions, 
foreign  bodies,  and  the  patency  or  obstruction  of  the  openings  leading 
to  the  accessory  sinuses,  may  be  determined. 

Instruments. — The  instruments  comprise  those  necessary  for  a 
rhinoscopic  examination;  a  nasal  applicator;  a  nasal  probe;  and  a 
sinus  probe  (Fig.  322). 

The  nasal  probe  should  be  of  silver,  fairly  stiff,  but  at  the  same 



time  capable  of  being  bent.  It  should  be  about  8  inches  (20  cm.) 
long,  and  set  into  its  handle  at  an  angle  of  135  degrees. 

The  instrument  employed  for  examination  of  the  sinuses  must  be 
of  pure  soft  silver  and  tine  in  size  so  that  it  may  be  readily  bent  to  any 
curve  or  be  adjusted  to  the  shape  of  the  region  through  which  it  has  to 

Asepsis. — The  speculum,  applicator,  and  probes  are  sterilized  by 

Anesthesia. — The  nasal  mucous  membrane  is  very  sensitive  and 
manipulations  are  apt  to  produce  sneezing,  so  that  the  parts  should 
be  cocainized  before  the  probe  is  employed.  This  may  be  done  by 
applying  a  4  per  cent,  solution  on  a  small  pledget  of  cotton,  allowing 
sufficient  time  to  elapse  for  the  cocain  to  take  eflfect  before  proceeding 
with  the  examination. 

Fig.  322. — Instruments  for  palpating  the  interior  of  the  nose.      I,    Nasal  ap- 
plicator; 2,   nasal    probe;  3,    sinus    probe;  4,    Myles'    nasal    speculum;  5,    head 

Position  of  Patient. — The  positions  of  the  patient  and  operator  are 
the  same  as  for  a  rhinoscopic  examination  (see  page  312). 

Technic. — By  means  of  a  speculum  and  reflected  light  the  interior 
of  the  nasal  cavity  is  brought  into  view  and  is  then  systematically 
explored  by  the  probe.  Any  growths  are  touched  to  determine  their 
consistency,  and  masses  that  may  be  hidden  beneath  the  turbinates  and 
otherwise  escape  attention  may  be  rolled  into  view  by  means  of  the 
probe.  The  condition  of  the  mucous  membrane,  the  presence  and 
depth  of  ulcerations,  etc.,  are  ascertained.  All  recesses  should  be 
thoroughly  examined,  and  especially  the  walls  of  the  sinuses  should 
be  gently  palpated  for  the  presence  of  dead  bone. 

In  the  presence  of  symptoms  or  signs  pointing  to  involvement  of 
the  sinuses,  the  sinus  probe  should  be  employed  to  determine  their 



condition  and  the  patency  of  their  ostia  as  a  preliminary  to  irrigation. 
On  account  of  the  anatomical  arrangement  of  the  parts,  probing  is 
practically  limited  to  the  sphenoidal  and  frontal  sinuses  unless  the 
middle  turbinate  is  first  removed.  Before  making  any  exploration  of 
these  cavities,  any  visible  pus  or  discharge  is  wiped  away  and  the 
nasal  cavity  cleansed  by  syringing. 

Fig.  323. — Showing  the  steps  in  the  passage  of  a  probe  into  the  frontal  sinus. 

To  enter  the  frontal  sinus,  the  distal  end  of  the  probe,  bent  to  an 
angel  of  135  degrees,  is  inserted  within  the  middle  meatus  at  the  junc- 
tion of  the  anterior  third  and  posterior  two-thirds  of  the  middle  tur- 
binate. Its  tip  is  made  to  hug  the  outer  wall  of  the  middle  turbinate, 
and  is  passed  upward  and  forward  through  the  hiatus  and  into  the 

Pig.  324. — Showing  the  steps  in  the  passage  of  a  probe  into  the  sphenoidal  sinus. 

infundibulum.  By  depressing  the  handle  of  the  instrument,  its  tip 
will  traverse  the  infundibulum  and  pass  through  the  ostium  frontale 
unless  some  obstruction  exists.  Gentleness  should  be  employed  in 
this  maneuver,  and  no  attempt  should  be  made  to  force  the  instru- 
ment if  any  obstruction  to  its  passage  exists. 



To  enter  the  sphenoidal  sinus,  the  end  of  the  probe  is  bent  to  a 
slight  curve  and  is  passed  into  the  nose  with  its  convexity  upward. 
The  tip  of  the  instrument  is  made  to  traverse  the  roof  of  the  nasal 
fossa  until  it  meets  the  resistance  of  the  anterior  sphenoidal  wall. 
The  probe  is  then  moved  gently  about  in  various  directions  until  its 
point  enters  the  cavity  of  the  sinus,  which  is  then  carefully  explored. 

In  either  case,  when  the  probing  is  employed  as  a  preliminary  to 
irrigation,  and  the  particular  sinus  has  been  successfully  entered  by 
the  probe,  if  the  shape  of  the  irrigator  be  made  to  correspond  to  that 
of  the  probe  it  will  be  of  great  help  in  the  introduction  of  the  former. 


Palpation  of  the  posterior  nares  by  means  of  the  finger  is  employed 
to  confirm  the  diagnosis  made  by  posterior  rhinoscopy,  or  to  obtain 

Fig.  325. — Showing  the  method  of  palpating  the  postnasal  space  with  the  finger. 

information  as  to  the  condition  of  these  parts  when  the  latter  is  not 
possible.  Xo  instruments  are  needed,  except  in  the  case  of  unruly 
children,  when  a  mouth  gag  may  be  required.  While  digital  palpa- 
tion is  a  rather  unpleasant  procedure  for  the  patient,  if  performed 
rapidly  and  skilfully  many  of  the  disagreeable  features  may  be 


Preparations. — The  operator's  hands  should  always  be  well 
scrubbed  before  making  such  an  examination. 

Technic. — It  is  well  to  first  explain  to  the  patient  what  is  intended 
to  be  done.  The  patient  is  then  directed  to  open  the  mouth  widely. 
The  left  hand  of  the  operator  supports  the  patient's  head,  and  at  the 
same  time  with  the  thumb  or  index  finger  of  the  same  hand  he  forces 
the  cheek  in  between  the  open  jaws  to  prevent  the  examining  finger 
from  being  bitten  (Fig.  325).  The  index  finger  of  the  right  hand  is 
then  gently  but  quickly  introduced  into  the  mouth  and  is  hooked 
around  the  posterior  border  of  the  soft  palate  into  the  nasopharynx, 
and  the  parts  are  palpated.  In  this  way  the  presence  of  adenoids, 
hypertrophies  of  the  posterior  ends  of  the  turbinates,  or  other  growths 
are  readily  recognized. 


Transillumination  is  a  valuable  aid  for  determining  the  conditiori 
of  the  frontal  or  maxillary  sinuses.  Its  use  in  connection  with  other 
sinuses  is  futile.  This  method  of  diagnosis  becomes  possible  from  the 
fact  that  the  air  spaces,  when  in  a  healthy  state,  transmit  light 
through  their  thin  walls,  which  power  is  diminished  when  pus  is 

Fig,  326. — Coakley's  transilluminator.  a,  Apparatus  assembled  for  trans- 
illumination of  the  antrum;  b,  glass  hood  for  use  in  transillumination  of  the  antrum; 
c,  hood  for  use  in  transillumination  of  the  frontal  sinus. 

present  or  the  mucous  membrane  lining  the  cavity  is  much  thickened. 
Transillumination  is  not  an  infallible  method,  by  any  means,  the 
chief  causes  of  error  being  imperfect  symmetry  of  the  two  sides,  due 
to  a  difference  in  the  size  of  the  two  sinuses  or  to  a  variation  in  the 
thickness  of  the  bony  walls.  Another  source  of  error  occurs  when 
involvement  of  both  sides  of  a  pair  of  sinuses  exists,  and  there  is  there- 
fore nothing  upon  which  to  base  a  comparison.  The  method  is  of 
greatest  service  in  the  diagnosis  of  empyema  of  the  antrum  and  of  the 
frontal  sinus.  In  the  latter  it  is  not  so  valuable  or  nearly  so  reliable 
an  aid  as  in  the  former,  for  the  size  of  the  two  frontal  sinuses  and  the 
thickness  in  the  individual  bones  are  apt  to  vary. 



Apparatus. — There  are  many  lamps  adapted  to  the  purpose  of 
transillumination,  Coakley's  being  an  excellent  model.  This  con- 
sists of  a  handle  of  nonconducting  material  containing  a  lamp  and 
glass  hood  for  transillumination  of  the  maxillary  sinus,  and  a  second 

\ /■ 


Fig.     327. — Transillumination  eflFect 
in  a  normal  right  frontal  sinus. 

Fig.  328. — Transillumination     effect 
in  a  diseased  left  frontal  sinus. 

hood  to  fit  over  the  lamp  in  place  of  the  glass  one.  for  use  about  the 
frontal  sinus  (Fig.  326).  The  lamps  are  of  about  four  or  five  candle- 
power,  the  electricity  being  supplied  by  a  small  battery  or  the  street 

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Fig.  329. — Transillumination  effect 
in  the  normal  case.  (After  Harmon 
Smith,  in  Keen's  Surgery.) 

Fig.  330. — Transillumination  effect 
in  sinusitis  of  the  right  antrum.  (After 
Harmon  Smith,  in  Keen's  Surgery.) 

current.     In  employing  the  latter,  a  current  controller,  by  which  the 
amount  of  current  may  be  regulated,  will  be  necessary. 

Technic. — i.  Transillumination     of    the     Frontal     Sinus. — The 
patient  is  seated  in  a  dark  room.     The  black  hood  is  drawn  over  the 



transilluminator  and  the  instrument  is  placed  beneath  the  orbital 
portion  of  the  brow  at  the  nasal  side.  The  light  is  turned  on  and  the 
sinus  is  clearly  illuminated,  the  operator  noting  the  effect.  The  oppo- 
site side  is  treated  in  the  same  manner,  and  the  two  are  compared  as 
to  the  intensity  with  which  the  light  is  transmitted. 

Through  a  large  sinus  in  a  normal  condition  the  light  is  transmitted 
with  greater  intensity  than  through  a  small  cavity,  or  through  one 
with  thickening  of  the  bony  walls  or  the  lining  membrane,  or  one 
complicated  by  the  presence  of  pus  or  a  tumor. 

2.  Transillumination  of  the  Antrum. — The  patient  is  seated  in  a 
darkened  room,  any  dental  plates  or  obturators  that  might  obstruct 
the  light  having  been  previously  removed.  The  electric  lamp, 
covered  with  the  glass  hood,  is  then  introduced  into  the  mouth,  and 
the  patient  is  instructed  to  close  his  lips  firmly.  Under  normal  con- 
ditions when  the  lamp  is  lighted,  the  cheeks,  up  to  the  infraorbital 
margins,  and  both  pupils  are  clearly  illuminated.  If  one  antrum  con- 
tains pus  or  a  solid  tumor,  the  malar  region  of  that  side  will  appear 
darker  and  an  absence  of  illumination  of  the  pupil  will  be  noted.  The 
transmission  of  light  will  also  be  interfered  with  in  the  presence  of 
thickened  walls  or  lining  mucous  membrane. 


The  X-ray  gives  important  information  in  regard  to  the  frontal, 
ethmoid,  and  maxillary  sinuses,  and,  when  possible,  it  should  be  regu- 
larly employed  as  one  of  the  aids  in  diagnosis.  To  be  of  any  value, 
however,  it  must  be  applied  by  a  competent  radiographer.  It  is 
especially  valuable  in  diseases  of  the  frontal  sinuses.  In  a  healthy 
condition,  the  outlines  of  the  sinuses  are  clear  and  distinct;  while  in 
diseased  conditions  the  outlines  are  not  so  clearly  indicated  and  the 
whole  area  of  the  sinus  appears  cloudy.  In  addition  the  X-ray  will 
show  the  size  and  shape  of  the  frontal  sinus  and  the  position  of  the 
septum,  all  of  which  are  important  points  in  making  a  decision  as  to 
method  of  operating,  should  it  be  necessary.  To  determine  the  size 
of  a  sinus  it  is  necessary  to  take  two  plates,  one  in  profile  and  the 
other  full  face. 

Therapeutic  Measures 


Nasal  douching  is  employed  for  the  purpose  of  cleansing  the  nasal 
cavity  prior  to  operative  procedures  or  for  the  purpose  of  removing 



secretions  or  crusts  preparatory  to  the  application  of  other  remedies. 
It  must  always  be  used  with  due  precautions,  for  there  is  considerable 
risk  where  fluid  is  forced  into  the  nose  in  bulk  that  some  of  it  will  enter 
the  Eustachian  tubes  and  cause  an  otitis  media.  For  this  reason 
only  small  quantities  of  solution  are  employed  at  a  time,  and  the  injec- 
tion should  be  made  without  any  force.  If  one  side  of  the  nose  is 
obstructed,  the  solution  should  enter  by  that  nostril  and  escape  from 
the  more  open  one.  As  a  further  precaution,  any  excess  of  fluid 
remaining  after  the  irrigation  should  be  allowed  to  flow  from  the  nose 
or  be  drawn  into  the  mouth  and  expectorated,  but  not  blown  from  the 
nose  for  fear  of  forcing  some  into  the  Eustachian  tubes.  The  patient 
should  furthermore  be  instructed  to  remain  indoors  for  at  least  half 
an  hour  after  each  irrigation  to  avoid  catching  cold.     For  the  patient's 

Fig.  331. — Nasal  douche  apparatus. 

own  use  nasal  spraying  is  a  safer  method  to  employ,  and,  if  it  becomes 
necessary  to  prescribe  a  nasal  douche,  the  surgeon  should  carefully 
instruct  the  patient  in  the  proper  method  of  its  use. 

Apparatus. — An  ordinary  douche  bag  with  a  capacity  of  about  a 
pint  (500  c.c),  fitted  with  a  nasal  nozzle,  forms  a  simple  and  effective 
douche.  There  are  a  number  of  douches  especially  made  for  the 
nose,  a  convenient  type  for  use  with  large  quantities  of  solution  being 
shown  in  Fig.  331.  It  consists  of  a  pint  bottle  to  the  bottom  of  which 
is  attached  a  rubber  tube  fitted  with  a  nasal  nozzle.  The  small  glass 
douche  (Fig.  332),  known  as  the  "Bermingham  douche,"  is  useful 
where  the  cleansing  is  to  be  carried  out  by  the  patient. 



Solutions. — For  ordinary  cleansing  purposes  the  solution  should 
be  alkaline  and  as  unirritating  as  possible. 

One  of  the  following  formulae  may  be  employed. 

I^.  Sodii  bicarbonatis, 

Sodii  biboratis, 

Acidi  carbolici, 


Aqu«,  q.   s.   ad. 

i^.  Sodii  bicarbonatis, 

Acidi  salicylici, 

Aquae,  q.   s.   ad. 

I^.  Sodii  bicarbonatis, 

Sodii  biboratis, 

Sodii  chloridi, 
Sig.  A  teaspoonful  to  a  pint  of  warm  water. 

aa.  dr.  i  (4  gm.) 
nrixv  (i  c.c.) 
oz.  i  (30  c.c.) 

Oi(5oo  c.c.)     M. 
dr.  i  (4  gm.) 
gr.  X  (0.65  gm.) 
Oi  (500  c.c.)     M. 

aa.  oz.  i  (30  c.c.)       M. 

Some  of  the  proprietary  preparations,  such  as  listerin,  borolyptol, 
glycothymolin,  alkalol,  etc.,  will  be  found  of  value  where  an  antiseptic 

Fig.  332. — The  Bermingham  nasal  douche. 

action  is  also  desired.  They  may  be  used  in  the  proportion  of  dr.  ss 
to  dr.  i  (2  to  4  c.c.)  to  the  ounce  (30  c.c.)  of  water.  When  there 
is  an  offensive  discharge,  the  following  may  be  employed. 

I^.  Potassii  permanganatis, 

gr.  i-ii  (o .  06-0 . 1  gm.) 
ad.  oz.   i  (30  c.c.)      M. 

Temperature. — All  solutions  should  be  used  warm,  at  a  tempera- 
ture of  about  100°  F.  (38°  C). 

Quantity. — For  ordinary  cleansing  purposes  or  for  the  removal 
of  free  secretion  from  the  nose,  a  few  ounces  of  solution  are  sufi&cient. 
When  hard  crusts  are  abundant,  however,  it  sometimes  requires  a 
pint  (500  c.c.)  of  solution,  or  more,  to  loosen  them  and  effect  their 

Rapidity  of  Flow. — The  solution  should  be  injected  with  only 
sufficient  force  to  permit  its  return  from  the  opposite  nostril  in  a  slow, 



gentle  stream — never  under  high  pressure.  Accordingly,  the  reser- 
voir should  be  raised  only  2  or  3  inches  (5  to  7.5  cm.)  above  the  level 
of  the  nose. 

Technic. — The  patient  sits  with  his  head  bent  slightly  forward 
over  a  basin  or  sink,  with  a  towel  or  napkin  placed  about  his  neck  for 
protection  of  the  clothes.  The  douche  nozzle,  held  in  the  right  hand, 
is  then  inserted  into  one  nostril  with  sufficient  firmness  to  prevent  the 
solution  from  escaping,  while  with  the  left  hand  the  reservoir  is  raised 
a  few  inches  so  that  the  solution  enters  the  nose  in  a  weak  stream. 
The  patient  is  directed  to  breathe  through  his  mouth  and  to  avoid 
swallowing  during  the  lavage.     In  this  way,   when  the  patient's 

Fig.  333. — vShowing  the  method  of  using  the  nasal  douche. 

head  is  bent  forward,  the  fluid  does  not  escape  into  the  pharynx,  but 
passes  through  one  nostril  back  into  the  nasopharynx  and  out  through 
the  other  nostril  (Fig.  t,2>3)-  When  no  obstruction  exists  in  either 
side,  half  the  solution  may  be  injected  through  one  nostril  and  the 
remainder  in  the  reverse  direction  through  the  other. 

With  the  small  glass  douche  cup  the  technic  is  very  simple. 
The  patient  inserts  the  nozzle  of  the  partially  filled  instrument  into 
one  nostril,  holding  the  finger  over  the  side  opening.  He  then  throws 
his  head  well  back  and  removes  his  finger  from  the  opening,  which 


allows  the  solution  to  flow  through  the  nose  into  the  mouth,  whence  it 
is  expectorated.     Each  nostril  in  turn  may  be  thus  irrigated. 


The  nasal  syringe  is  employed  mainly  for  cleansing  the  nose. 
The  solution  may  be  injected  either  from  the  front,  returning  through 
the  opposite  nostril,  after  the  manner  of  the  nasal  douche,  or  the  nose 
may  be  washed  out  from  behind  forward.  By  the  latter  method  the 
postnasal  space  may  be  more  effectually  cleansed  of  sticky  secretions 
and  mucus  than  by  injecting  the  solution  from  the  front.  The  same 
precautions  should  be  observed  in  using  the  syringe  as  have  been 
mentioned  for  the  use  of  the  douche. 

Instruments. — A  syringe  with  a  capacity  of  i  to  2  ounces  (30  to 
60  c.c),  made  of  metal  or  hard  rubber,  will  be  required.     It  should 

Fig.  334. — Xasal  sj^ringe  with  anterior  and  posterior  nasal  tips. 

be  supplied  with  a  straight  nozzle  for  injection  through  the  anterior 
nares,  and  with  one  bent  up  almost  at  right  angles  for  cleansing  the 
postnasal  space  (Fig.  334). 

Solutions. — Any  of  the  cleansing  solutions  mentioned  on  page 
327  may  be  employed.     They  should  always  be  used  warm. 

Technic. — In  employing  the  nasal  syringe  much  the  same  technic 
is  followed  as  with  the  douche,  observing  due  care  against  injecting 
the  solution  with  too  much  force,  etc.  The  nozzle  of  the  syringe  is 
inserted  into  one  nostril  and  the  patient  is  directed  to  keep  his  head 
bent  well  forward  over  a  receptacle  and  to  breathe  through  the 
mouth.  The  solution  is  then  slowly  injected  and  returns  through  the 
opposite  nostril.  The  irrigation  should  be  so  regulated  that  the  fluid 
returns  as  quickly  as  it  enters,  thus  avoiding  any  undue  accumulation 
in  the  postnasal  space  and  lessening  the  dangers  of  infecting  the  Eu- 
stachian tubes. 



To  syringe  from  the  posterior  nares,  a  tongue  depressor  is  intro- 
duced into  the  mouth  to  keep  the  tongue  out  of  the  way,  while  the 
distal  end  of  the  postnasal  tip  is  introduced  behind  the  soft  palate. 
The  patient  is  then  directed  to  hold  his  head  well  forward,  the  fluid  is 
slowly  injected  and  escapes  from  the  anterior  nares,  flushing  out  the 

Fig.  335. — Showing  the  method  of  syringing  the  nose  from  behind, 

postnasal  space  and  nose  from  behind  forward  (Fig.  335).  On 
account  of  the  sensitive  condition  of  the  parts  in  some  cases  it  may  be 
necessary  to  cocainize  the  pharynx  and  soft  palate  before  the  syring- 
ing can  be  properly  performed. 

Sprays  or  atomizers  are  utilized  either  for  cleansing  purposes  or 
for  the  application  of  remedies  to  the  nasal  mucous  membrane  when 
it  is  not  necessary  to  confine  the  solution  to  one  particular  spot. 

Fig.  336. — Whitall  Tatum  atomizer.   • 

Apparatus. — The  simplest  form  of  atomizer  usually  proves  most 
satisfactory,  and  is  less  liable  to  get  out  of  order.     The  Whitall  Tatum 



(Fig.  336),  the  Davidson,  or  the  De  Vilbiss  (Fig.  337)  are  all  good  at- 
•omizers.  The  latter  is  especially  serviceable,  and  the  spray  part, 
being  of  metal,  may  be  readily  sterilized.  The  instrument  should  be 
provided  with  a  straight  nasal  tip  as  well  as  with  a  postnasal  tip.  The 
air  current  may  be  supplied  by  a  rubber  compression  bulb  or  by  a 
compressed  air  apparatus  (Fig.  338).  The  latter  will  be  found  more 
convenient  for  ofi&ce  work. 

For  cleansing  purposes,  the  spray  should  be  rather  coarser  than 
that  employed  for  medication.     Oily  preparations  may  be  sprayed 

Fig.  337. — De  Vilbiss  atomizer. 

with  an  ordinary  atomizer  provided  with  an  oil  tip,  or  a  special  oil 
nebulizer  may  be  employed. 

Solutions. — Any  of  the  cleansing  solutions  mentioned  on  page  327 
may  be  employed  in  a  spray. 

Fig.  338. — Compressed-air  atomizing  apparatus. 
When  a  mild  antiseptic  action  is  desired,  the  solutions  given  on 

page  327  or  the  following  may  be  used: 

I^.  Acidi  carbolici 
Aquae  q, 

gr.  V  (0.3  gm.) 
dr.  i  (4  c.c.) 
s.  ad.  oz.  i  (30  c.c.)     M. 


I^.  Resorcini,  gr.  iii  (0.2  c.c.) 

Glycerini,  dr.  i  (4  c.c.) 

Aquae,  q.  s.  ad.  oz.  i  (30  c.c.)     M. 

Astringent  solutions,  for  purposes  of  lessening  secretions,  include 
such  drugs  as  zinc  sulphocarbolate,  zinc  sulphate,  copper  sulphate, 
alum,  tannic  acid,  silver  nitrate,  etc.,  used  in  the  strength  of  5  gr. 
(0.3  gm.)  to  the  ounce  (30  c.c.)  of  water. 

Oily  preparations,  with  albolene  or  benzoinol  as  a  base,  are  fre- 
quently used  after  the  application  of  aqueous  solutions  for  the  purpose 
of  protecting  the  parts,  the  oil  being  deposited  upon  the  mucous 
membrane  in  a  thin  coat.  Usually  eucalyptol,  camphor,  menthol,  or 
thymol  are  combined  with  the  oil  in  the  proportion  of  2  to  5  gr.  (o.i 
to  0.3  gm.)  or  more  to  the  ounce  (30  c.c.)  for  the  sedative  effect,  as 
in  the  following: 

I^.  Eucalyptol,  T([x  (0.6  c.c.) 

Menthol,  gr.  v  (0.3  gm.) 

Benzoinol,  oz.  i  (30  c.c.)     M. 

I^.  Thymol, 

Menthol,  aa  gr.  ii  (o.i  gm.) 

Albolene,  oz.  i  (30  c.c.)     M. 

I^.  Camphors. 

Menthol,  aa  gr.  v  (0.3  gm.) 

Albolene,  oz.  i  (30  c.c.)     M. 

When  a  stimulating  action  is  indicated,  the  proportion  of  the 
above  drugs  may  be  increased. 

Technic. — The  tip  of  the  nose  is  gently  raised  and  the  nozzle  of 
the  spray  is  inserted  into  the  vestibule.  To  avoid  injuring  the 
mucous  membrane  of  the  septum  or  turbinates,  care  should  be  taken 
to  keep  the  long  axis  of  the  spray  and  that  of  the  nose  in  the  same  line. 
By  alternately  compressing  and  relaxing  the  rubber  bulb,  the  solution 
is  forced  into  the  nose  in  a  spray.  The  direction  of  the  spray  should 
be  altered  from  time  to  time  by  raising  or  lowering  the  proximal  end 
of  the  atomizer. 

For  spraying  from  the  posterior  nares,  the  same  technic  is 
employed  as  with  the  postnasal  syringe  (see  page  330). 


This  method  is  employed  for  the  application  of  strong  solutions  or 
sohd  caustics,  or  when  it  is  desired  to  confine  the  action  of  the  remedy 
to  any  particular  area. 



Fig.  339. — Fusing  chromic  acid  on  a  probe.     First  step,  heating  the  probe. 


Fig.  340. 

Fig.  341. 

Fig.  342. 

Fig.  340. — Fusing  chromic  acid  on  a  probe.  Second  step,  dipping  the  hot 
probe  in  the  crystals.      (Gleason.) 

Fig.  341. — Fusing  chromic  acid  on  a  probe.  Third  step,  heating  the  crystals 
into  a  bead.     (Gleason.) 

Fig.  342. — Fusing  chromic  acid  on  probe.  Showing  the  finished  probe. 


Instruments. — For  the  application  of  solutions,  a  nasal  applicator, 
the  tip  of  which  is  wound  with  a  thin  layer  of  cotton,  is  employed. 
Solid  caustics,  as  chromic  acid,  silver  nitrate,  etc.,  are  best  applied 
fused  upon  a  probe  or  applicator. 

Chromic  acid  may  be  prepared  for  application  as  follows:  The 
probe  tip  is  brought  to  a  red  heat  over  an  alcohol  flame  (Fig.  339) 
and  is  then  dipped  into  crystals  of  the  acid  (Fig.  340).  Upon  with- 
drawing the  probe  a  few  crystals  will  be  found  adhering  to  its  point. 
This  mass  is  then  heated  in  the  flame  until  the  crystals  begin  to  melt 
(Fig.  341),  and,  upon  cooling,  they  recrystallize  in  the  form  of  a  bead 
on  the  end  of  the  instrument  (Fig.  342).  If  it  is  desired  to  employ 
silver  nitrate  in  this  way,  a  few  of  the  crystals  should  be  melted  in  a 
crucible.  The  tip  of  a  probe  or  applicator  is  then  dipped  into  this 
liquid  mass  until  sufficient  of  the  caustic  adheres,  and,  as  soon  as  it 
solidifies,  it  is  ready  for  use.  In  applying  chromic  acid  a  second  cot- 
ton-wrapped applicator,  saturated  with  a  solution  of  bicarbonate  of 
soda — 30  gr.  (2  gm.)  to  the  ounce  (^o  c.c.) — should  be  at  hand  to 
neutralize  any  excess  of  acid. 

Anesthesia. — The  parts  should  be  cocainized  by  the  appHcation  of 
a  4  per  cent,  solution  of  cocain. 

Technic. — The  mucous  membrane  is  well  cleansed,  and,  when 
using  caustics,  the  area  to  be  treated  is  rendered  as  dry  as  possible  to 
prevent  the  caustic  spreading  over  too  large  a  surface.  The  appli- 
cation is  then  made  to  the  diseased  spot  under  guidance  of  the  nasal 
speculum,  being  careful  not  to  allow  the  applicator  to  touch  any  other 
points.  If  acid  is  employed,  any  excess  is  immediately  neutralized 
with  the  strong  solution  of  bicarbonate  of  soda  by  means  of  an  applica- 
tor previously  prepared  and  in  readiness. 


Various  powders  with  sedative  or  antiseptic  properties  are  applied 
to  the  nasal  mucous  membrane  by  means  of  a  special  powder  blower. 
Finely  powdered  starch,  stearate  of  zinc,  or  powdered  acacia  is  usu- 
ally employed  as  a  base,  in  the  proportion  of  two  parts  to  one  of  the 
active  principle.  Nosophen,  aristol.  europhen,  iodoform,  iodal,  etc., 
are  remedies  frequently  applied  in  this  manner.  Morphin  and  cocain 
in  small  doses  may  be  combined  with  these  powders  when  indicated. 

Instruments. — The  insufflator  shown  in  Fig.  343  or  that  shown  in 
Fig.  344  may  be  used.  The  former  is  made  on  the  same  principle 
as  a  hand  spray,  but  with  larger  tubes.  It,  however,  requires  the 
use  of  both  hands  in  its  manipulation.     The  latter  instrument  con- 



sists  of  a  rubber  compression  bulb  to  which  is  fitted  a  vulcanized 
rubber  tube.  Into  this  latter  fits  the  nasal  tip,  the  proximal  end  of 
which  is  made  in  the  form  of  a  scoop  for  taking  up  the  powder.  When 
the  instrument  is  filled,  a  sudden  compression  of  the  bulb  forces  air 
through  the  apparatus,  blowing  the  powder  out  in  front  of  it.     This 

Fig.  343. — Powder  blower. 

instrument  may  be  manipulated  with  one  hand,  and  the  quantity  of 
powder  used  can  be  accurately  measured.  Insuffiators  are  supplied 
with  straight  tips  for  the  anterior  nares,  and  with  curved  tips  for 
making  applications  to  the  posterior  nares. 

Fig.  344. — Scoop  powder  blower. 

For  the  patient's  use,  an  insufflator  such  as  Sajous'  (Fig.  345)  will 
be  found  convenient.  It  consists  of  a  small  glass  receptacle  with  an 
opening  for  pouring  in  the  powder,  to  one  end  of  which  a  rubber 
mouthpiece  is  attached,  the  other  end  being  rounded  off  to  fit  into  the 

Fig.  345. — Sajous'  powder  blower. 

Technic. — With  a  suitable  powder  blower,  the  application  of 
powders  is  very  simple.  The  instrument  being  properly  filled,  the 
tip  is  inserted  into  the  nostril  or  up  behind  the  soft  palate,  according 


to  whether  the  anterior  or  the  posterior  portions  of  the  nose  are  to 
be  medicated,  and,  with  two  or  three  rapid  compressions  of  the  bulb, 
the  powder  is  forced  out  of  the  instrument  and  is  deposited  upon  the 
mucous  membrane. 

When  the  insufflation  is  performed  by  the  mouth,  as  with  the 
Sajous  insufflator,  the  tip  is  inserted  into  the  nostril,  the  instrument 
being  held  with  one  finger  over  the  opening  in  the  bottom  of  the 
receptacle  to  make  it  air-tight.  The  mouthpiece  is  held  between  the 
lips  and,  by  one  or  more  gentle  puffs,  the  powder  is  blown  out  upon  the 
parts  to  be  medicated. 


This  procedure  is  employed  as  a  means  of  diagnosis,  for  the  purpose 
of  removing  purulent  secretions,  and  for  cleansing  the  mucous 
lining  in  the  treatment  of  suppuration  involving  the  accessory  sinuses. 
It  is  performed  by  means  of  a  suitable  cannula  introduced  into  the 
sinus  through  the  natural  or  an  artificial  opening.  Treatment  by 
irrigation  is  most  successful  in  the  early  cases  of  empyema;  in  those 
complicated  by  granulation  tissue  or  dead  bone,  it  is  not  so  satisfac- 
tory. It  should,  however,  be  given  a  trial  in  any  case  before  the  more 
radical  surgical  measures  are  considered. 

Solutions  Used. — Normal  saline  solution  (salt  oi  (4  gm.)  to  the 
pint  (500  c.c.)  of  boiled  water),  a  saturated  solution  of  boric  acid, 
or  any  of  the  cleansing  solutions  mentioned  on  page  327  may  be  used. 

Temperature. — All  solutions  employed  in  irrigating  should  be 
warm — at  about  100°  F.  (38°  C). 

Lavage  of  the  Maxillary  Sinus. — It  is  rarely  possible  to  insert  a 
probe  or  cannula  into  the  maxillary  sinus  through  its  normal  opening, 
on  account  oi  its  hidden  position  and  the  fact  that  the  opening  is 
directed  somewhat  downward  and  forward  from  the  infundibulum. 
If  an  accessory  opening  be  present,  however,  it  may  be  possible  to 
irrigate  through  it,  but  in  most  cases  an  artificial  opening  will  have  to 
be  made  through  the  inferior  turbinate,  or  through  the  alveolus  after 
removal  of  the  second  bicuspid,  or  the  first  or  second  molar  tooth. 
The  former  approach  should  be  chosen  when  the  teeth  are  sound  and 
the  origin  of  infection  is  apparently  from  the  nose.  When  a  decayed 
tooth  is  the  source  of  trouble  and  the  tooth  is  beyond  saving,  puncture 
through  the  alveolus  is  justifiable. 

Instruments. — For  irrigating  through  the  inferior  meatus,  an 
antrum  trocar  and  cannula  and  small  syringe  will  be  required.  For 
opening  through  the  alveolus,  there  should  be  provided  suitable  tooth- 



Fig.  346. — Instruments  for  lavage  of  the  maxillary  sinus  through  a  puncture  in 
the  inferior  meatus.  I,  Head  mirror;  2,  syringe;  3,  applicator;  4,  Myles'  nasal 
speculum;  5,  tubing  to  connect  the  syringe  and  cannula;  6,  Myles'  trocar  and 

Fig.  347. — Instruments  for  lavage  of  the  antrum  through  the  alveolus,  i. 
Syringe;  2,  cannula;  3,  tubing  to  connect  the  syringe  to  the  cannula;  4,  alveolar 
drill;  5,  drainage-tube;  6,  tooth-extracting  forceps. 



pulling  forceps,  an  alveolar  drill,  a  syringe,  and  a  silver  or  aluminum 
tube  of  the  same  caliber  as  the  drill,  1/2  to  3/4  inch  (i  to  2  cm.)  long 
and  provided  with  a  flange  to  prevent  its  slipping  into  the  antrum. 

Asepsis. — The  instruments  are  sterilized  by  boiling,  and  the 
patient's  nose  is  cleansed  by  gentle  syringing. 

Anesthesia. — For  puncture  of  the  antrum  through  the  inferior 
meatus,  local  anesthesia  by  the  application  of  a  4  per  cent,  solution  of 
cocain  on  a  pledget  of  cotton  twenty  minutes  before  will  be  sufficient. 

Nitrous  oxid  anesthesia  should  be  employed  for  the  extraction 
of  a  tooth  and  drilling  through  the  alveolus. 

Technic. —  i.  Through  the  Inferior  Meatus. — Having  obtained  a 
good  view  of  the  interior  of  the  nose  by  the  aid  of  a  speculum  and 
reflected  light,  a  point  is  selected  just  beneath  the  inferior  turbinate 

Fig.  348. — Showing  the  method  of  puncturing  the  antrum  through  the  inferior 


and  about  1/2  inch  (i  cm.)  behind  its  anterior  extremity,  and  the 
trocar  is  introduced,  pushing  it  in  an  outward,  backward,  and  slightly 
upward  direction,  through  the  thin  bony  wall  into  the  antrum  (Fig. 
348).  The  relation  of  the  sinus  to  the  orbit  should  be  borne  in 
mind  when  making  this  puncture  and  care  taken  not  to  enter  the  lat- 
ter; this  may  happen  if  the  puncture  be  made  through  the  middle 
meatus  (Fig.  349).  As  soon  as  the  antrum  has  been  entered,  the 
trocar  is  withdrawn.  The  syringe  is  then  attached  to  the  cannula  by 
a  piece  of  rubber  tubing,  and  the  cavity  thoroughly  irrigated.  Any 
secretion  is  thus  forced  out  through  the  normal  opening  of  the  sinus 
and  appears  in  the  middle  meatus.  During  the  irrigation,  the  head 
should  be  held  downward  over  a  receptacle,  so  that  the  solution  will 
readily  escape  from  the  nose. 

The  sinus  should  be  irrigated  daily  until  the  discharge  ceases, 
employing  stronger  or  more  stimulating  solutions  if  they  seem  indi- 
cated.    Usually  there  is  no  great  difficulty  in  reinserting  the  cannula 



through  the  opening  each  day,  if  it  is  provided  with  a  blunt  obturator. 
The  parts  should  be  cocainized,  however,  before  each  irrigation. 

2.  Through  the  Alveolus. — The  puncture  is  made  through  the 


/Intfuirt  of 


Fig.  349. — Transverse  section  through  the  nose,  showing  cannula,  a.  Entering 
antrum  through  inferior  meatus;  and  h,  cannula  entering  the  orbit  through  the 
middle  meatus.      (After  Coffin.) 

socket  of  the  second  bicuspid  or  the  inner  root  socket  of  the  first  or 
second  molar  tooth  (Fig.  350).  The  affected  tooth  is  first  removed, 
and  the  drill  inserted  by  a  boring  motion,  as  follows:  For  the  first 
molar,  in  an  upward  and  slightly  inward  direction;  for  the  second 

Fig.  350. — Showing   drills   entering   the   antrum   through   the   alveolus.      (After 
Schultze  and  Stewart.) 

molar,  in  an  upward,  slightly  inward  and  forward  direction;  and  for 
the  second  bicuspid,  upward,  slightly  inward,  and  backward.  Unless 
the  approximate  position  of  the  antrum  is  kept  in  mind  and  the  drill 
inserted  accordingly,  the  cavity  may  be  missed.     As  soon  as  the  an- 



trum  has  been  entered  the  cavit}-  is  irrigated  by  means  of  a  syringe,  the 
solution  escaping  into  the  nose  through  the  natural  opening.  To  aid 
its  escape,  the  patient's  head  should  be  inclined  forward.  Finally,  a 
metal  drainage-tube  of  the  proper  size  is  inserted,  through  which 
subsequent  irrigations  may  be  made. 

The  irrigations  may  be  performed  once  or  twice  a  day,  and  later 
they  may  be  carried  out  by  the  patient  himself.  When  the  discharge 
ceases,  the  irrigations  are  discontinued  for  a  day  or  two,  and,  if  there 
is  no  recurrence  of  the  trouble,  the  tube  is  then  removed  and  the 
opening  allowed  to  close. 

Lavage  of  the  Frontal  Sinus. — The  frontal  sinus  may  be  irri- 
gated by  means  of  a  small  cannula  introduced  through  the  fronto- 

FiG.  351. — Instruments  for  lavage  of  the  frontal  sinus.  i.Myles'  nasal  speculum; 
2,  head  mirror;  3,  syringe;4,  tubing  to  connect  the  syringe  to  cannula ;  5,  sinus  probe; 
6,  nasal  applicator;  7,  sinus  cannula. 

nasal  duct.  In  some  cases,  where  the  opening  is  occluded  by  the 
middle  turbinate  or  an  enlarged  bulla  ethmoidahs,  the  middle  turbi- 
nate will  have  to  be  removed  before  the  attempt  is  successful. 
Another  difficulty  presents  itself  in  the  close  proximity  of  the  anterior 
ethmoidal  cells,  and  the  cannula  may  enter  this  group  instead  of  the 
frontal  sinus. 

Instruments. — A  head  mirror,  a  speculum,  a  nasal  applicator,  a 
sinus  probe,  a  pure  soft-silver  sinus  cannula  that  may  be  easily  bent  to 



accommodate  itself  to  any  curve — such  as  Hartmann's — and  a  syr- 
inge that  can  be  attached  by  means  of  rubber  tubing  will  be  required 
(Fig.  351). 

Fig.  352. — Showing  the  steps  of  passing  a  cannula  into  the  frontal  sinus. 

Asepsis. — The  instruments  are  sterilized  by  boiling,  and  the 
patient's  nose  is  cleansed  by  gentle  syringing. 

Anesthesia. — A  4  per  cent,  solution  of  cocain  should  be  applied 
to  the  middle  meatus  for  twenty  minutes  before  the  operation. 

^  A.  <>  6 

Fig-  353- — Instruments  for  lavage  of  the  sphenoidal  sinus,  i,  Myles'  nasal 
speculum;  2,  head  mirror;  3,  syringe;  4,  tubing  to  connect  the  syringe  to  cannula; 
5,  sinus  probe;  6,  nasal  applicator;  7,  sinus  cannula. 

Technic. — The  cannula,  bent  at  its  distal  end  to  an  angle  of  about 
135  degrees,  is  introduced  into  the  middle  meatus  at  the  junction  of 
the  anterior  third  with  the  posterior  two-thirds.     The  tip  of  the 



cannula  is  passed  into  the  hiatus  and  then  forward  and  upward  into 
the  infundibulum.  and  thence  still  upward  and  slightly  forward  into 
the  sinus,  through  the  fronto-nasal  duct  (Fig.  352).  The  syringe  is 
then  attached  to  the  cannula  and  the  sinus  is  gently  irrigated  with  one 
of  the  warm  cleansing  solutions  previously  mentioned. 

Lavage  of  the  Sphenoidal  Sinus. — Instruments. — A  head  mirror, 
a  nasal  speculum,  a  nasal  applicator,  a  sinus  probe,  a  sphenoidal 
curved  cannula,  and  a  syringe  with  rubber-tubing  attachment  will 
be  required  (Fig.  353). 

Asepsis. — The  instruments  are  boiled,  and  the  patient's  nose  is 
cleansed  by  gentle  syringing. 

Anesthesia. — The  region  is  anesthetized  with  a  4  per  cent,  solu- 
tion of  cocain. 

Technic. — The  cannula  is  passed  into  the  nasal  cavity  with  the 
convexity  upward.     The  point  of  the  instrument  is  inserted  between 

Fig.  354. — Showing  the  steps  of  passing  a  cannula  into  the  sphenoidal  sinus. 

the  middle  turbinate  and  the  septum,  and  should  follow  the  roof  of  the 
nose  until  it  meets  the  resistance  of  the  anterior  wall  of  the  sphenoidal 
sinus.  By  gently  moving  the  instrument  up  and  down  and  from  side 
to  side,  its  tip  will  eventually  be  made  to  enter  the  sphenoidal  opening 
(Fig.  354).  The  depth  of  the  sinus  is  only  about  3/8  inch  (1.5  cm.), 
and  care  should  be  taken  not  to  force  the  instrument  through  its  thin 
walls.  The  syringe  is  attached  to  the  cannula  by  rubber  tubing,  and 
the  cavity  thoroughly  but  gently  irrigated.  During  this  procedure 
the  patient's  head  should  be  bent  forward  and  the  mouth  opened  to 
prevent  the  backward  flow  of  the  returning  solution. 



The  beneficial  effects  of  passive  hyperemia  in  the  treatment  of 
inflammations  have  aheady  been  discussed  in  Chapter  IX,  to  which 
section  the  reader  is  referred  for  a  full  consideration  of  the  subject 
and  the  technic  of  its  application.  According  to  Ballenger/  the  indi- 
cations for  passive  hyperemia  in  rhinology  are:  (i)  in  the  first  five 
days  of  acute  rhinitis;  (2)  in  the  first  five  days  of  acute  sinusitis;  (3) 
in  the  first  five  days  of  acute  inflammation  of  the  pharyngeal  tonsils; 
(4)  in  acute  tubal  catarrh;  (5)  in  chronic  purulent  inflammation  of 
the  sinuses. 

The  hyperemia  may  be  effected  by  means  of  a  neck-band  (as 
described  on  page  210)  or  by  a  special  form  of  suction  apparatus. 
The  latter  is  more  efiicacious  in  the  presence  of  a  purulent  discharge, 
the  vacuum  serving  to  remove  secretions  as  well  as  to  induce  a  benefi- 
cial hyperemia;  but  it  must  be  used  with  great  care  not  to  induce  a 
harmful  degree  of  hyperemia.  The  apparatus  shown  in  Fig.  196  or 
one  provided  with  glass  tips  which  fit  into  the  nostrils  may  be  used. 
With  the  apparatus  applied  to  the  nose,  the  air  is  slowly  rarefied 
while  the  patient  swallows.  This  causes  the  soft  palate  to  rise  up  in 
apposition  with  the  posterior  wall  of  the  pharynx  and  to  close  the 
naso-pharynx  and  nose  from  the  pharynx,  and  a  hyperemia  of  the 
mucous  membrane  of  naso-pharynx,  nose,  accessory  sinuses,  and 
Eustachian  tubes  is  thus  induced. 


Nasal  hemorrhage  may  be  the  result  of  trauma,  ulcerations, 
new  growths,  cardiac  disease,  certain  constitutional  diseases  and  infec- 
tions, diseases  of  the  blood,  etc.  Usually  the  bleeding  ceases  spontane- 
ously or  under  simple  treatment  which  aims  at  lessening  the  conges- 
tion of  the  nasal  mucous  membrane  and  favoring  the  formation  of  a 
clot,  such  as  the  appKcation  of  cold  over  the  nose  and  at  the  base 
of  the  neck,  removing  tight  collars,  etc.,  from  the  neck,. or  having 
the  patient  remain  quietly  in  an  upright  position  with  the  head 
erect,  at  the  same  time  forbidding  any  attempts  at  blowing  the  nose. 

If  these  simple  measures  are  insuf&cient,  a  speculum  should  be 
introduced  and  the  interior  of  the  nose  inspected  for  the  source  of 
the  hemorrhage.     If  the  bleeding  point  is  within  reach,  it  should 

1  Ballenger:  "Diseases  of  the  Nose,  Throat,  and  Ear." 



be  cauterized  by  touching  with  the  electro-cautery  or  with  silver 
nitrate;  or  else  some  styptic  solution,  as  peroxid  of  hydrogen,  a 
watery  solution  of  tannic  acid,  or  a  i  to  looo  solution  of  adrenalin 
chlorid  should  be  appHed  to  the  part  upon  a  pledget  of  cotton.  It 
may  be  impossible  to  locate  the  bleeding  point,  or  the  hemorrhage 
may  continue  in  spite  of  such  treatment,  so  that  in  the  presence  of 

Fig.  355. — Instruments  for  tamponing  the  anterior  nares.    i,  Nasal  applicator; 
2,  head  mirror;  3,  narrow  strip  of  gauze;  4,  Myles'  nasal  speculum. 

a  profuse  hemorrhage  it  becomes  necessary  to  pack  the  nose.  In 
the  majority  of  cases  tamponade  through  the  anterior  nares  will 
be  sufficient;  in  others,  the  bleeding  may  occur  posteriorly  and  the 
posterior  nares  as  well  will  have  to  be  packed. 

Instruments,  etc. — To  pack  the  nose  from  the  front,  a  head  mir- 

FlG.  356. — Catheter  for  drawing  plug  into  the  posterior  nares. 

ror,  a  nasal  speculum,  a  nasal  applicator,  and  a  single  narrow  strip  of 
gauze  should  be  provided  (Fig.  355). 

For  packing  the  posterior  nares  a  tampon  about  i  inch  (2 . 5  cm.) 
long  and  1/2  inch  (i  cm.)  thick,  should  be  prepared  by  rolling  a 
strip  of  gauze  to  the  required  size,  to  the  center  of  which  a  heavy 
piece  of  silk  thread  is  tied,  the  two  ends,  which  should  each  be  about 
28  inches  (45  cm.)  long,  being  left  free.     For  the  purpose  of  adjusting 



the  tampon  in  place,  a  rubber  urethral  catheter  of  a  size  that  will 
readily  pass  through  the  nose  into  the  mouth  (Fig.  356),  or  an  instru- 
ment especially  made  for  this  purpose,  known  as  Bellocq's  sound 
(Fig.  357),  will  be  necessary.  This  latter  consists  of  a  curved 
metal  cannula  containing  a  concealed  steel  spring,  which  is  protruded 

Fig.  357. — Bellocq's  cannula. 

into  the  pharynx  and  mouth  when  the  cannula  is  in  place  in  the  nose, 
and  to  the  end  of  which  the  tampon  is  then  attached. 

Asepsis. — The  instruments  are  boiled,  and  the  gauze  used  for  the 
tampon  should  be  sterile. 

Fig.  358. — Showing  the  method  of  tamponing  the  anterior  nares. 

Technic  {Anterior  Nares). — In  tamponing  the  anterior  nares  a 
speculum  is  inserted  in  the  nose  and  a  good  view  of  the  interior 
obtained.  A  narrow  strip  of  gauze,  saturated  with  peroxid  of  hydro- 
gen, is  then  gently  carried  well  back  into  the  nose  by  means  of  an 
applicator,  and  by  forcing  in  more  gauze  the  whole  nose  is  tamponed 



and  the  hemorrhage  controlled  (Fig.  358).  This  packing  should 
always  be  removed  within  forty-eight  hours.  Only  a  single  strip  of 
gauze  should  be  used,  as  it  will  be  less  difficult  to  remove  and  there  is 

Fig.  359. — Showing  the  method  of  drawing  a  plug  into  the  posterior  nares  by  the 

aid  of  Bellocq's  cannula. 

Fig.  360. — The  posterior  nasal  plug  in  place. 

no  danger  of  leaving  any  behind  in  the  nose.     As  a  further  aid  in 
removal,  the  end  of  the  gauze  should  be  left  within  easy  reach. 

(2)   {Posterior  Nares). — The  tampon,  as  already  described,  should 


be  well  lubricated  with  sterile  vaselin  and  placed  near  at  hand.  The 
Bellocq  cannula  is  passed  along  the  floor  of  the  nose  on  the  bleeding 
side  until  its  tip  appears  back  of  the  soft  palate.  The  steel  spring  is 
pushed  home  and  is  protruded  into  the  mouth.  The  tampon  is  then 
tied  to  the  end  of  the  carrier  by  one  of  the  strings  (Fig.  359),  the 
spring  returned  within  the  cannula,  and  the  latter  removed  from  the 
nose  and  with  it  the  end  of  the  tampon  spring.  By  pulling  upon  the 
string,  assisted  by  a  finger  placed  in  the  naso-pharynx,  the  tampon  is 
drawn  tightly  into  the  posterior  nares  (Fig.  360).  In  addition,  it  is 
well  to  pack  the  anterior  nares  with  gauze  or  a  plug  of  cotton,  over 
which  is  tied  the  string  protruding  from  the  nose.  The  other  end  of 
the  string,  which  is  left  in  place  for  the  purpose  of  removing  the  pack, 
is  brought  out  through  the  mouth  and  loosely  fastened  to  the  ear. 
When  an  ordinary  catheter  is  employed  in  place  of  a  special  sound, 
precisely  the  same  technic  is  followed. 

The  packing  should  be  removed  in  twenty-four  hours,  since,  if 
left  in  longer,  it  is  apt  to  set  up  an  irritation  and  may  lead  to  infection 
of  the  Eustachian  tube.  To  remove  the  pack,  the  string  tied  to  the 
anterior  tampon  is  first  cut  free.  The  naso-pharynx  should  be 
cleaned  of  blood-clots,  and  the  whole  region  sprayed  with  adrenalin 
chlorid  to  cause  the  tissues  to  shrink  as  much  as  possible.  The  poste- 
rior plug  is  then  removed  by  gentle  traction  upon  the  string. 


Anatomic  Considerations 

The  ear  is  divided  into  three  portions:  the  external  ear,  the  middle 
ear,  and  the  internal  ear.  For  the  purposes  of  this  work,  a  consid- 
eration of  the  anatomy  of  the  external  ear  and  the  middle  ear  will 

The  external  ear  comprises  the  auricle  or  pinna  and  the  external 
auditory  canal. 

The  auricle  is  the  irregular  shaped  mass  composed  of  fibrocartilage, 
covered  by  perichondrium,  connective  tissue,  and  skin,  which  pro- 
jects from  the  side  of  the  head.  It  has  the  function  of  collecting 
sounds  and  reflecting  them  to  the  external  auditory  meatus.     The 

Fig.  361. — The  left  auricle,      i,  Concha;  2,  antihelix;  3,  fossa  of  antihelix;  4,  helix; 
5,  fossa  of  the  helix;  6,  tragus;  7,  antitragus;  8,  lobule. 

central  depressed  portion,  resembHng  a  shell  in  form,  is  called  the  con- 
cha. It  is  bounded  by  a  rim,  the  antihelix,  which  runs  at  first  back- 
ward and  then  upward  and  forward,  finally  dividing  into  two  arms. 
The  space  between  these  two  arms  is  known  as  the  fossa  of  the  anti- 
helix. From  the  front  portion  of  the  concha  extends  a  ridge,  known 
as  the  helix,  at  first  in  a  forward  and  upward  direction  and  then 
around  the  circumference  of  the  auricle  toward  the  lowest  portion. 
The  space  between  the  antihelix  and  the  helix  is  designated  the  fossa 
of  the  helix.     The  small  backward  projection  lying  in  front  of  the  con- 




cha  is  called  the  tragus,  and  the  small  tubercle  at  the  lowest  portion 
of  the  antihelix,  the  antitragus.  The  lobule  of  the  ear  is  the  lowest 
soft  pendulous  portion  of  the  auricle. 

The  external  auditory  canal  extends  from  the  concha  to  the  drum 
membrane.  It  serves  the  purpose  of  conveying  sounds  collected  by 
the  auricle  to  the  drum  membrane.  The  canal  measures  about 
I  1/2  inches  (4  cm.)  in  length,  the  floor  being  slightly  longer  than  the 
roof  on  account  of  the  oblique  position  of  the  drum  membrane.  Its 
outer  third  is  composed  of  cartilage,  a  continuation  of  that  forming 
the  auricle,  while  the  inner  two-thirds  has  a  bony  framework.  The 
interior  is  lined  with  thin  skin,  which  contains  hair  follicles  and 
cerumenous  glands,  the  latter  being  most  abundant  at  the  junction 

/top/' ct/"  7j//npanum. 



laid  open 

Fig.  362. — Front  view  of  the  organ  of  hearing.      (Randall.) 

of  the  cartilaginous  and  bony  portions.  The  widest  portion  of  the 
canal  is  near  the  external  orifice,  the  narrowest  portion  near  the 
center,  and,  beyond  this,  as  it  nears  the  drum  membrane,  the  canal 
expands  again.  The  direction  of  the  canal  traced  from  without 
inward  is  at  first  upward  and  forward,  then  backward,  and  finally 
forward  and  downward.  By  traction,  however,  in  an  upward,  back- 
ward, and  outward  direction  upon  the  auricle  the  canal  may  be 
straightened  out  and  its  interior  viewed. 

The  middle  ear,  or  tympanum,  is  an  irregularly  shaped  cavity 
situated  in  the  petrous  portion  of  the  temporal  bone,  between  the 
external  and  the  internal  ear.  The  interior  of  the  cavity  is  lined  with 
a  delicate  mucous  membrane.  Within  it  lie  the  chain  of  ossicles,  the 
tympanic  muscles,  and  the  chorda  tympani  nerve. 



The  tympanic  cavity  is  bounded  above  by  the  roof,  consisting  of  a 
thin  plate  of  bone,  the  tegmen  tympani  et  antri,  which  separates  it 
from  the  dura;  below  by  the  floor  which  corresponds  to  the  jugular 
fossa;  by  an  outer  wall  composed  of  the  drum  membrane  and  the 
ring  of  bone  into  which  it  is  inserted;  by  an  inner  wall  which  is  con- 
tiguous to  the  labyrinth,  and  presents  an  oval  window  closed  by  the 
stapes  and  a  round  window  closed  by  membrane;  by  an  anterior  wall 
which  separates  the  tympanic  cavity  from  the  carotid  canal,  and  in 
the  upper  part  of  which  is  the  tympanic  orifice  of  the  Eustachian  tube 
and  above  this  the  canal  for  the  tensor  tympani  muscle;  and  by  a 
posterior  wall^  in  the  upper  part  of  which  lies  the  narrow  opening 
leading  into  the  mastoid  antrum,  the  aditus  ad  antrum.     The  cavity 






Fig.  363. — Anatomy  of  the  ossicles.      (Pyle's  "Personal  Hygiene.") 

is  practically  divided  by  the  chain  of  ossicles  into  two  portions,  an 
upper  epitympanic  space  or  attic,  and  a  lower  cavity  or  atrium. 

The  ossicles  are  three  small  bones,  the  malleus  or  hammer,  the 
incus  or  anvil,  and  the  stapes  or  stirrup,  joined  together  by  movable 
articulations,  and  forming  an  osseous  chain  between  the  drum  mem- 
brane and  the  labyrinth.  They  are  held  in  place  by  the  attachment 
of  the  malleus  to  the  membrana  tympani  and  of  the  stapes  to  the 
oval  window,  and  in  addition  by  various  ligaments  extending  between 
them  and  the  bony  walls.  Their  function  is  to  convey  sound  waves 
from  the  drum  to  the  labyrinth. 

The  malleus  consists  of  an  oval  head  which  extends  upward  and 
articulates  with  the  incus,  a  neck,  a  manubrium  or  handle  which 


extends  downward  and  is  embedded  in  the  membrana  tympani,  a 
short  process,  which  extends  outward  from  the  neck  to  the  membrana 
tympani  and  pushes  the  latter  outward  before  it,  and  a  long  process 
which  passes  anteriorly  into  the  Glaserian  fissure. 

The  incus  is  the  middle  ossicle.  It  consists  of  a  body  which  artic- 
ulates with  the  malleus,  a  short  horizontal  process  which  extends  to 
the  posterior  wall  where  it  is  attached  by  ligaments,  and  a  long  process 
which  extends  downward  and  outward  and  then  near  its  tip  sharply 
inward  to  articulate  by  its  orbicular  process  with  the  head  of  the 

The  stapes  consists  of  a  broad  base  or  foot-piece  which  fits  into  the 
oval  window,  to  the  membrane  of  which  it  is  attached,  two  crura  or 
legs,  and  a  head  which  articulates  with  the  orbicular  process  of  the 

The  membrana  tympani,  or  ear-drum,  is  a  thin  elastic  membrane 

Fig.  364. — Outer  surface  of  the  right  membrana  tympani.  (Gleason.)  a, 
Membrana  flaccida;  h,  posterior  fold;  c,  short  process;  d,  incudostapedial  articula- 
tion; e,  malleus  handle;/,  umbo;  g,  cone  of  light. 

stretched  obliquely  downward  and  inward  across  the  inner  end  of  the 
external  auditory  canal  forming  the  outer  wall  of  the  tympanic 
cavity.  The  drum  membrane  is  made  up  of  three  layers,  an  outer  one 
of  skin,  a  middle  of  fibrous  tissue,  and  an  inner  formed  by  the  reflec- 
tion of  the  mucous  membrane  of  the  middle  ear.  It  serves  the 
purpose  of  receiving  and  transmitting  sound  waves  to  the  chain  of 

It  may  be  described  as  elliptical  in  outline,  and  of  a  pearly  gray 
color,  but  at  the  same  time  translucent.  Its  outer  surface  is  concave 
and  normally  smooth.  By  the  aid  of  a  speculum  and  suitable  illumi- 
nation there  will  be  noted  a  whitish  ridge  formed  by  the  handle  of  the 
malleus,  running  from  a  tubercle  near  the  upper  and  anterior  per- 
iphery downward  and  backward  toward  the  center  of  the  membrane. 
This  tubercle  represents  the  short  process  of  the  malleus.  Where  the 
handle  of  the  malleus  ends  near  the  center  of  the  membrane  is  a 
depression,  the  umbo.     Under  illumination  in  the  anterior  and  lower 

352  THE    EAR 

quadrant  of  the  drum  will  also  be  noted  a  triangular  area  of  light  (the 
reflection  of  light)  with  its  apex  at  the  tip  of  the  handle  and  its  base 
at  the  periphery  of  the  drum.  Extending  anteriorly  and  posteriorly 
from  the  short  process  of  the  malleus  are  two  delicate  folds  of  mem- 
brane which  divide  the  drum  into  two  portions.  That  portion  above 
these  folds  is  known  as  Shrapnell's  membrane,  or  the  membrana 
flaccida,  and  that  below  as  the  membrana  tensor. 

The  Eustachian  tube  is  a  canal  about  i  1/2  inches  (4  cm.)  long, 
connecting  the  pharynx  with  the  tympanic  cavity.  It  has  a  general 
direction  from  the  tympanum  forward,  downward,  and  inward, 
opening  upon  the  lateral  wall  of  the  pharynx  near  the  inferior  meatus 
of  the  nose  in  front  of  Rosenmiiller's  fossa  as  a  crater-like  eminence. 
The  tube  is  made  up  of  a  framework  which  in  the  outer  third  is  bony 
and  in  the  inner  two-thirds  cartilaginous  and  membranous,  and  is 
lined  with  ciliated  epithelium  which  waves  in  a  direction  toward  the 
pharynx.  The  two  ends  are  enlarged,  but  approaching  the  juncture 
of  the  osseous  and  cartilaginous  portions  the  tube  narrows  consider- 
ably. Normally  the  walls  are  in  apposition,  but  when  the  palatal 
muscles  contract,  as,  for  example,  in  the  act  of  swallowing  or  yawn- 
ing, the  walls  are  separated.  The  function  of  the  Eustachian  tube 
is  to  equalize  the  atmospheric  pressure  on  the  outer  and  inner  sides 
of  the  drum,  and  to  provide  drainage  for  the  tympanic  cavity  and 
mastoid  cells. 

Diagnostic  Methods 

A  complete  examination  of  the  ear  should  comprise  a  clinical  his- 
tory, an  examination  of  the  nasopharynx,  and  then  an  investigation 
of  the  ear  itself. 

A  history  is  quite  essential,  but  it  need  not  necessarily  be  an 
exhaustive  one.  It  should  first  be  ascertained  what  symptoms  or 
symptom  the  patient  complains  of,  and  whether  only  one  ear  or  both 
are  affected.  The  duration  of  the  trouble  is  also  of  importance,  as  it 
has  considerable  bearing  upon  the  prognosis  in  any  given  case.  The 
probable  cause  of  the  condition  should  also  be  determined  as  far  as 
is  possible  by  careful  questioning.  Among  the  many  etiological 
factors  of  ear  diseases  are  severe  colds,  grippe,  some  injury,  insects, 
acute  infectious  diseases,  syphilis,  tuberculosis,  etc.  The  symptoms 
or  symptom  complained  of  should  then  be  investigated  more  in  detail. 

Deafness  and  tinnitus  are  the  common  complaints  for  which  relief 
is  sought,  and  are  frequently  associated.     In  the  presence  of   the 


former  it  should  be  learned  whether  the  deafness  developed  slowly  or 
suddenly,  whether  one  or  both  ears  are  involved,  and,  if  the  latter  be 
the  case,  which  ear  is  more  affected.  The  duration  of  the  condition 
must  also  be  ascertained.  Not  infrequently  in  the  presence  of 
chronic  catarrh  of  the  middle  ear,  the  patient,  while  not  actually  deaf, 
will  complain  of  certain  disturbances  of  hearing,  as,  for  example,  the 
ability  to  hear  better  in  the  presence  of  noise,  as  on  a  railroad  train  or 
street  car  (paracusis  Willisii),  or  hearing  sounds  as  if  repeated  twice 
(paracusis  duplicata),  or,  again,  in  the  presence  of  marked  unilateral 
deafness  the  inability  to  locate  the  source  of  sounds  (paracusis 
localis) . 

Tinnitus,  or  subjective  noises,  are  present  in  middle-ear  diseases 
as  well  as  affections  of  the  internal  ear,  in  neurasthenic  conditions, 
arteriosclerosis,  and  may  follow  the  taking  of  certain  drugs,  as,  for 
example,  quinin  or  the  salicylates.  They  may  be  described  by  the 
patient  as  singing,  whisthng,  buzzing,  loud  and  roaring  or  musical 
in  character,  or  they  may  resemble  voices.  When  present,  it  should 
be  learned  whether  they  are  located  in  the  ear  or  in  the  head,  whether 
unilateral  or  bilateral,  and  whether  they  are  modified  by  mental  or 
physical  exertion  or  by  the  time  of  day.  As  a  rule  they  are  worse  at 
night,  and  in  some  cases  they  may  be  entirely  absent  during  the  day. 

In  the  presence  of  pain  or  earache,  its  character,  the  duration, 
and  whether  constant  or  intermittent  should  be  noted.  Pain  may  be 
the  result  of  morbid  conditions  in  the  ear  or  it  may  be  reflex,  as,  for 
example,  from  a  decayed  tooth,  or  from  an  inflammation  of  the 
pharynx,  tonsils,  etc.  When  it  suddenly  develops  in  an  ear  previously 
healthy  it  generally  points  to  an  acute  inflammation  of  the  middle  ear, 
while,  if,  on  the  other  hand,  it  occurs  during  the  course  of  some  chronic 
affection  of  the  ear,  a  coUection  of  fluid  in  the  middle  ear  or  destruc- 
tion of  bone  may  be  suspected.  Pressure  tenderness  is  also  of  diag- 
nostic importance  in  determining  the  origin  of  the  trouble.  Thus, 
pain  caused  by  traction  upon  the  auricle  or  by  pressure  on  the  tragus 
points  to  an  inflammation  involving  the  external  auditory  canal, 
tenderness  elicited  by  pressure  in  the  depression  below  the  lobule  of 
the  ear  to  middle-ear  inflammation,  and  pressure  tenderness  over  the 
mastoid  to  involvement  of  that  bone. 

The  presence  or  absence  of  a  discharge  is  next  determined.  With 
a  history  of  a  discharging  ear,  the  length  of  time  the  discharge  has 
lasted,  the  character  of  the  discharge,  whether  serous,  bloody,  or 
purulent,  whether  scanty  or  in  large  amounts  and  whether  continuous 
or  intermittent  should  be  noted.  It  is  also  important  to  ascertain  if 

354  THE    EAR 

the  discharge  is  accompanied  by  pain,  and  the  relation  the  pain  and 
the  discharge  bear  to  one  another. 

In  addition  to  the  above  points,  the  occupation  and  habits  of  the 
patient  should  be  investigated  as  having  an  etiological  bearing  upon 
the  case,  and  in  certain  cases  a  general  physical  examination  should  be 
made.  One  should  never  fail  to  investigate  the  condition  of  the  nose 
and  throat,  especially  the  nasopharynx,  noting  the  presence  or 
absence  of  congestion,  swelling  of  the  mucous  membrane,  adenoid 
growths,  ulcers,  etc.,  and  the  condition  of  the  pharyngeal  ends  of  the 
Eustachian  tubes.  The  technic  of  such  examination  has  already  been 
described  in  Chapter  XIII.  The  parts  in  the  vicinity  of  the  ear 
should  likewise  be  inspected  as  well  as  palpated  for  signs  of  inflamma- 
tion, swellings,  new  growths,  enlarged  glands,  or  signs  of  tenderness. 
Having  completed  these  preliminaries,  the  actual  examination  of  the 
ear  should  be  instituted. 

The  examination  of  the  ear  comprises  (i)  direct  inspection  of  the 
external  ear,  (2)  inspection  of  the  external  auditory  canal  and  tym- 
panic membrane  by  the  aid  of  specula,  (3 )  determination  of  the 
mobility  of  the  drum  membrane,  (4)  various  tests  of  the  power  of 
hearing,  and  (5)  determination  of  the  patency  of  the  Eustachian 
tubes.  la  all  cases  the  examiner  should  not  fail  to  investigate  the 
condition  of  both  ears. 


A  thorough  inspection  of  the  auricle  and  external  auditory  canal 
should  always  precede  the  use  of  a  speculum.  In  this  way  the  exam- 
iner may  be  enabled  to  recognize  pathological  conditions  at  the 
entrance  of  the  auditory  canal  that  might  otherwise  escape  attention 
or  be  hidden  from  view  by  the  speculum. 

Instruments. — All  that  is  required  is  suitable  illumination.  This 
may  be  furnished  by  means  of  an  electric  head  light  (see  Fig.  311),  or 
by  means  of  light  reflected  upon  the  part  by  means  of  a  head  mirror. 

Position  of  Patient. — The  patient  is  seated  upon  a  stool  with  the 
ear  to  be  examined  turned  toward  the  surgeon,  who  is  also  seated  upon 
a  stool  of  such  height  that  his  eyes  are  on  a  level  with  the  ear  of  the 
patient.  If  reflected  light  is  employed,  the  source  of  illumination 
should  be  a  little  above  the  level  of  the  patient's  ear  and  upon  the 
examiner's  left  side. 

Technic. — Under  full  illumination  the  auricle  is  first  carefully 
inspected,  noting  the  presence  or  absence  of  excoriations  from  dis- 



charges,  eczema,  swellings,  deformities,  new  growths,  etc.  Then  by 
means  of  traction  upon  the  auricle  in  an  upward  and  backward  direc- 
tion, the  external  auditory  canal  is  straightened  out  and  a  view  of  a 
considerable  portion  of  its  interior  becomes  possible.  The  examiner 
should  note  especially  the  color  of  the  canal  for  signs  of  inflammation, 
the  presence  or  absence  of  swellings,  fissures,  foreign  bodies,  new 
growths,  etc. 


Otoscopy  is  the  inspection  of  the  external  auditory  canal  and 
tympanic  membrane  by  the  aid  of  a  speculum  and  suitable  illumina- 
tion. By  this  means  parts  of  the  auditory  canal  and  the  drum  mem- 
brane invisible  to  direct  inspection  may  be  viewed  in  detail,  and  the 
presence  or  absence  of  pathological  conditions  recognized. 

Instruments. — There  will  be  required  a  strong  light,  such  as  is 
obtained  from  a  Welsbach  burner  covered  by  a  Mackenzie  condenser, 

Fig.  365. — Instruments  for  otoscopy,      i,    Head  mirror;  2,  aural  specula;  3,  ear 
probe;  4,  ear  curet;  5,  angular  ear  forceps;  6,  ear  syringe. 

mounted  upon  an  adjustable  bracket  so  that  it  may  be  raised  to  any 
desired  height,  a  concave  head  mirror  3  1/2  to  4  inches  (9  cm. 
to  10  cm.)  in  diameter  with  a  central  perforation  for  the  eye,  three 
sizes  of  metal  aural  specula,  a  fine  ear  curet,  a  probe,  a  pair  of 
PoUtzer  angular  ear  forceps,  and  an  ear  syringe  (Fig.  365).  If 
desired,  in  place  of  reflected  light,  illumination  from  an  electric  head 
light  may  be  substituted. 

For  purposes  of  examination  Gruber's  specula  (Fig.  366)  are  most 
satisfactory,  as  they  are  elliptical  in  shape  upon  transverse  section 
thus  corresponding  to  a  transverse  section  of  the  external  auditory 
canal.  Where,  however,  operative  procedures  are  indicated  a  spec- 
ulum with  a  wide  proximal  end  that  will  permit  the  manipulation  of 



instruments,  such  as  Boucheron's  (Fig.  367)  or  Toynbee's  is  prefer- 
able. Electric-lighted  specula^  (Fig.  368)  are  now  used  to  a  large 
extent,  and  simplify  the  operation  considerably. 

Asepsis. — To  avoid  carrying  infection  from  one  patient  to  another 
the  instruments  employed  in  otoscopy  should  be  boiled  or  immersed 

Fig.  366. — Gruber's  speculum. 

Fig.  367. — Boucheron's  speculum. 

in  a  I  to  20  carbolic  acid  solution  and  then  rinsed  in  sterile  water 
and  dried  before  use. 

Position  of  Patient. — The  patient  and  examiner  should  be  seated, 
the  former  with  the  ear  turned  toward  the  examiner.  The  examiner's 
eyes  should  be  on  a  level  with  the  patient's  ear  and  in  a  horizontal 

Fig.  368.— Electric-lighted  speculum. 

plane  with  the  external  auditory  canal.  If  reflected  light  is  employed, 
the  source  of  illumination  should  be  a  little  above  the  level  of  the 
patient's  ear  and  upon  the  examiner's  left. 

^  Manufactured  by  the  Electro-Surgical  Instrument  Co.  of  Rochester,  N.  Y. , 
and  the  Wappler  Co.,  New  York  City. 



Technic. — The  examiner  directs  the  light  full  upon  the  external 
auditory  meatus  and,  grasping  the  auricle  between  the  thumb  and 
index  finger  of  the  left  hand  (if  the  right  ear  is  being  examined  and 
vice  versa),  makes  traction  in  an  upward,  backward,  and  slightly 
outward  direction,  to  straighten  out  the  auditory  canal.  In  infants, 
to  accomplish  this,  it  is  necessary  to  pull  the  auricle  outward  and  a  lit- 
tle downward,  as  the  wall  of  the  canal  has  no  bony  support  at  this 
time  and  lies  collapsed  against  the  side  of  the  head.  The  speculum  is 
then  warmed  and,  grasped  by  its  rim  between  the  thumb  and  index 
finger  of  the  right  hand,  it  is  gently  introduced  by  a  slight  rotary 
motion  until  it  has  passed  the  junction  of  the  cartilaginous  and  bony 
portions  of  the  canal.  In  inserting  the  instrument,  care  must  be 
taken  to  follow  the  long  axis  of  the  auditory  canal,  by  watching  the 

Fig.  369. — Otoscopy  with  the  reflector  and  ear  specuhim. 
course  of  light.     (Gleason.) 

The  arrows  represent 

parts  illuminated  at  the  distal  end  of  the  speculum  until  the  drum 
membrane  is  brought  to  view.  With  the  speculum  properly  in  place, 
the  left  hand  is  shifted  from  the  auricle  to  hold  the  speculum,  the  right 
hand  being  thus  left  free  to  manipulate  any  instruments  (Fig.  369). 
Before  examining  the  drum  membrane,  the  external  auditory 
canal  should  be  inspected,  noting  its  color,  size  and  shape,  and  the 
presence  or  absence  of  foreign  bodies,  polypi,  discharges,  secretions, 
or  cerumenous  plugs.  Signs  of  inflammation  and  furuncles  should 
also  be  looked  for.  Sometimes  secretions  and  collections  of  wax 
require  removal  before  inspection  is  possible.  This  may  be  accom- 
plished, as  a  rule,  by  gently  syringing  the  canal  with  warm  saline 



solution  or  a  saturated  solution  of  boric  acid  (see  page  370).  Small 
masses  of  wax  and  flakes  may  require  removal  by  means  of  the  curet, 
followed  by  gentle  syringing.  The  ear  is  then  thoroughly  dried  by 
means  of  small  mops  of  sterile  cotton  held  in  angular  forceps  or 
wrapped  about  the  tip  of  a  probe. 

The  examiner  next  inspects  the  drum  membrane.  It  is  placed  at 
the  distal  end  of  the  canal,  inclining  downward  and  inward  at  an  angle 
of  about  45  degrees.  The  normal  drum  appears  translucent  and  of  a 
pearly  gray  color,  with  its  circumference  appearing  as  a  white  line. 
Extending  from  above  downward  and  backward  in  the  upper  half  of 
the  drum  is  seen  the  handle  of  the  malleus.  In  the  upper  and  anterior 
portion  about  1/25  inch  (i  mm.)  from  the  superior  wall  is  the  short 
process  of  the  malleus,  and  running  forward  and  backward  above  the 
short  process  are  two  folds  of  membrane  above  which  lies  Shrapnell's 
membrane.  Extending  from  the  tip  of  the  malleus  toward  the  per- 
phery,  in  the  lower  and  anterior  quadrant,  will  be  noted  the  bright 

Fig.  370. — The  appearance  of  the  drum  membrane  as  seen  through  the  specukim. 

cone  of  reflected  light.  In  addition  to  these  landmarks  normally  to 
be  observed,  if  the  membrane  is  very  thin  and  retracted,  there  may  be 
seen  the  long  process  of  the  incus  as  a  whitish  line  running  down 
behind  and  parallel  to  the  handle  of  the  malleus. 

On  inspection  of  the  drum  membrane,  one  should  note  first  its 
color,  whether  congested  and  red  and  if  uniformly  so,  also  whether 
translucent,  as  it  normally  should  be,  or  thickened  and  exhibiting 
localized  opacities.  The  presence  or  absence  of  granulations  or 
perforations  should  also  be  determined,  the  latter  being  evidenced  by 
the  greater  depth  of  the  drum  at  the  point  of  perforation.  Note  also 
if  the  membrane  is  retracted  or  bulging  with  fluid.  If  retracted,  the 
short  process  of  the  malleus  appears  more  plainly,  the  handle  is  short- 


ened,  and  the  conical  folds  are  deepened.  At  the  same  time  the  cone 
of  reflected  Hght  will  appear  altered  in  shape  and  displaced.  If  bulg- 
ing is  present,  its  location  should  be  noted.  As  a  rule,  bulging  occurs 
in  the  posterior  portion  of  the  membrane,  or  the  entire  drum  may  be 
distended.  If  it  occurs  in  the  upper  portion  only,  involvement  of 
the  attic  is  present.  By  changing  the  position  of  the  speculum 
slightly  all  portions  of  the  drum  may  be  viewed  in  detail.  By  means 
of  a  cotton-tipped  probe,  inspection  may  be  supplemented  by  careful 
palpation,  if  further  information  as  to  the  conditions  found  is  desired. 
In  all  manipulations  of  the  speculum  or  instruments  great  gentleness 
should  be  observed. 


By  the  aid  of  a  pneumatic  otoscope  with  which  the  air  in  the  exter- 
nal auditory  canal  may  be  alternately  condensed  or  rarefied,  it  is  pos- 
sible to  determine  the  degree  of  mobility  possessed  by  the  membrana 

Fig.  371. — Siegle's  pneumatic  otoscope. 

tympani,  and  thus  recognize  undue  rigidity  or  laxness  of  the  drum  or 
the  existence  of  intratympanic  adhesions  binding  the  drum  or  ossicles 
to  the  walls  of  the  tympanum. 

Apparatus. — Siegle's  pneumatic  otoscope  (Fig.  371)  consists  of 
an  air-tight  chamber,  the  proximal  end  of  which  is  closed  by  a  plain 
glass  window  or  convex  lens  placed  at  an  angle  of  45  degrees  to  the 
long  axis  of  the  instrument,  while  to  the  distal  end  may  be  screwed 
different  sized  specula.  Upon  the  side  of  the  air-tight  chamber  is 
placed  a  small  perforated  knob  to  which  is  attached  a  piece  of  rubber 
tubing  and  a  hand  bulb.  The  instrument  may  be  obtained  with  an 
electric  light  in  its  interior  or  illumination  may  be  supplied  by  an 
electric  head  light  or  reflected  light  from  a  head  mirror. 

360  THE    EAR 

Position  of  Patient. — The  patient  and  the  operator  occupy  the 
same  relative  positions  as  employed  for  an  ordinary  otoscopic  exam- 
ination (see  page  356) . 

Asepsis. — The  speculum  portion  of  the  instrument  should  be 
sterilized  by  boiling. 

Technic. — Some  of  the  air  is  expelled  from  the  bag  which  is  held 
in  the  examiner's  right  hand,  and  the  instrument  is  fitted  snugly  into 
the  auditory  canal  in  the  same  manner  as  an  ordinary  speculum.  A 
small  piece  of  rubber  tubing  may  be  slipped  over  the  end  of  the  specu- 
lum, if  necessary,  to  insure  its  fitting  the  auditory  canal  more  accu- 
rately. The  examiner  then  observes  under  good  illumination  the 
movement  of  the  drum  membrane  through  the  window  in  the  oto- 
scope, as  he  relaxes  or  compresses  the  bulb.  As  the  air  is  rarefied,  the 
drum  is  sucked  outward  and  becomes  convex  in  shape.  As  the  air 
is  condensed  by  compression  of  the  bulb,  the  drum  membrane 
moves  inward  and  becomes  more  concave.  The  presence  of  adhe- 
sions will  be  evidenced  by  absence  of  any  mobility  at  that  particu- 
lar point,  while  other  parts  of  the  drum  will  move  freely.  Too  ener- 
getic use  of  the  instrument  must  be  avoided  for  fear  of  rupturing 
a  weakened  drum. 


Hearing  tests  are  very  important  in  the  diagnosis  of  ear  diseases, 
since  they  not  only  furnish  information  as  to  the  extent  the  hearing  is 
impaired,  but  also  serve  to  localize  the  seat  of  a  lesion,  that  is,  whether 
in  the  conducting  apparatus  or  in  the  nervous  mechanism.  While 
there  have  been  a  number  of  hearing  tests  devised,  the  following  are 
sufficient  for  all  practical  purposes:  (i)  testing  the  acuteness  of  hear- 
ing by  means  of  the  watch  and  voice,  (2)  testing  the  perception  of  high 
and  low  notes,  (3)  Weber's,  and  (4)  Rinne's  test. 

Apparatus. — While  it  is  of  advantage  to  have  a  complete  set  of 
tuning-forks,  the  ordinary  tests  may  be  carried  out  with  a  low  tone 
fork  (C-2)  having  thirty-two  vibrations  per  second,  a  Galton's  whistle 
for  high  tones,  and  a  C  2  fork  having  512  vibrations  per  second 
for  Weber's  and  Rinne's  tests.  Galton's  whistle  gives  tones  ranging 
from  about  7000  vibrations  per  second  to  the  highest  perceptible  tone 
limit.  The  instrument  is  provided  with  a  scale  and  screw  whereby 
the  nimiber  of  vibrations  may  be  regulated  so  as  to  give  any  tone 
wnthin  the  Hmits  stated  above. 

Tests  of  the  Acuteness  of  Hearing. — i.  The  Watch  Test. — The 
test  is  made  in  a  room  free  from  noise  and  with  a  watch  that  ticks 



rather  loudly.  Since  the  ticking  of  different  watches  varies  con- 
siderably, the  distance  at  which  the  particular  watch  is  heard  by  a 
normal  ear  must  be  determined  by  experience.  Each  ear  is  tested 
separately  in  the  following  manner:  The  patient  is  seated  in  a  chair 

A  ^ 






/  V 


Pig.  372. — Hartmann's  set  of  tuning-forks  vanning  from  128  vs.  to  2048  vs. 

with  his  eyes  closed,  and  with  his  forefinger  closing  the  ear  not  under 
examination.  The  examiner  first  holds  the  ticking  watch  close  to 
the  ear  being  tested  so  that  the  patient  can  hear  it  distinctly  and  then 
slowdy  brings  it  from  a  distance  beyond  the  range  of  hearing  power 
toward  the  ear  in  a  line  perpendicular  to  the  auricle  until  the  patient 

Fig.  373. — Edelmann's  modification  of  Galton's  vv-histle. 

again  recognizes  the  ticking.  The  distance  from  the  ear  at  which  the 
ticking  is  heard  is  then  accurately  measured,  and  the  result  is 
expressed  in  a  fraction  of  inches,  the  denominator  of  which  represents 
the  number  of  inches  at  which  the  particular  watch  is  normally  heard 

362  THE    EAR 

and  the  numerator  the  number  of  inches  it  is  heard  by  the  ear  under 
examination.  For  example,  if  the  watch  is  heard  at  forty  inches  (100 
cm.)  by  the  normal  ear  and  the  patient  hears  it  at  ten  inches  (^25  cm.) 
the  result  is  expressed  as  10/40. 

2.  The  Voice  Test. — The  patient  is  seated  in  a  large  room  with  the 
eyes  closed  and  the  ear  not  under  examination  plugged  with  the  fore- 
finger. The  examiner  then  repeats  words  of  one  syllable  or  numerals 
in  an  ordinary  voice  and  also  in  a  whisper  at  the  end  of  expiration  with 
the  residual  air  from  various  distances,  and  measures  the  distance  at 
which  the  patient  can  hear  and  repeat  them  correctly.  The  result  is 
expressed  in  a  fraction  of  feet,  the  denominator  of  which  represents 
the  distance  in  feet  at  which  the  normal  ear  can  hear  the  voice  and 
the  numerator  the  actual  distance  at  which  it  is  heard  by  the  ear 
under  examination.  In  employing  this  test  it  is  important  that 
the  patient  does  not  see  the  lips  of  the  examiner  and  that  the  sounds 
are  transmitted  to  the  ear  under  examination  at  right  angles  to  the 

Testing  the  Perception  of  Different  Notes. — The  normal 
range  of  hearing  in  adults  for  musical  notes  lies  between  16  and  48,000 
vibrations  per  second.  The  majority  of  individuals,  however,  possess 
a  more  Kmited  range  than  this,  varying  from  about  24  to  16,000  vibra- 
tions per  second.  In  this  test  the  hearing  is  tested  for  low  tones  with 
a  low-toned  fork  and  for  high  tones  with  the  Galton  whistle.  The 
test  is  of  diagnostic  value  in  differentiating  between  disturbance  of 
hearing  due  to  affections  of  the  conducting  and  those  of  the  percep- 
tive apparatus.  Where  the  conduction  apparatus  is  at  fault  high 
tones  are  heard  better  than  low,  while  in  diseases  of  the  perceptive 
apparatus,  the  low  tones  are  heard  well,  but  high-tone  hearing  is  lost 
or  diminished.  It  should  be  remembered,  however,  that  in  advancing 
age  the  upper  tone  limit  is  lowered. 

Weber's  Test. — It  is  employed  for  the  purpose  of  locating  the 
seat  of  unilateral  deafness.  In  this  test  a  C  2  (512  vs.)  fork  is  set 
vibrating  and  the  handle  is  placed  on  the  incisor  teeth  or  upon  the 
cranium  in  the  mid-line.  If  the  sound  is  heard  best  in  the  affected 
ear.  it  is  indicative  of  some  aft'ection  of  the  conduction  apparatus,  as 
middle-ear  disease,  impacted  cerumen,  or  occlusion  of  the  Eustachian 
tube,  while  if  the  perceptive  apparatus  is  at  fault,  it  will  be  heard 
better  in  the  normal  ear. 

Rinn6's  Test.- — This  test  depends  upon  the  fact  that  aerial  con- 
duction is  better  than  bony  conduction.  In  a  normal  ear.  if  a  C  2 
(512  vs.)  fork  be  placed  upon  the  mastoid  until  the  patient  no  longer 


"hears  any  sound,  and.  if  the  fork  is  then  brought  close  to  the  external 
ear.  the  sound  will  again  be  heard.  This  is  known  as  a  positive  Rinne. 
If.  however,  the  sound  is  not  heard  again  when  the  fork  is  thus  trans- 
posed, it  is  known  as  a  negative  Rinne.  Therefore,  in  a  deaf  ear,  if 
we  obtain  a  positive  Rinne,  it  is  indicative  of  a  lesion  in  the  perceptive 
apparatus,  while  if,  under  the  same  conditions,  the  test  is  negative, 
it  shows  that  bony  conduction  is  increased;  i.e.,  there  is  some  obstruc- 
tion or  disease  of  the  conduction  apparatus. 


Inflation  of  the  middle  ear  has  both  diagnostic  and  therapeutic 
value.  As  a  diagnostic  measure  it  is  employed  to  determine  the  pat- 
encv  of  the  Eustachian  tubes,  that  is,  whether  or  not  an  unobstructed 
communication  exists  between  the  middle  ear  and  the  pharynx;  for 
the  purpose  of  detecting  the  presence  or  absence  of  an  exudate  in  the 
middle  ear,  and.  if  so.  the  character  of  the  exudate;  to  detect  the  pres- 
ence of  a  perforation  of  the  membrana  tympani;  and  to  determine  the 
mobility  of  the  membrana  tympani.  The  therapeutic  uses  of  infla- 
tion will  be  considered  later  (see  page  376). 

An  auscultatory  tube  is  employed  in  conjunction  with  inflation 
for  the  purpose  of  determining  whether  air  enters  the  middle  ear  and 
to  distinguish  the  character  of  the  sound  produced  which  is  of  diag- 
nostic importance.  Thus,  in  a  normal  condition  of  the  Eustachian 
tubes  and  tympanic  cavity,  air  -^^11  be  heard  to  enter  the  middle  ear 
with  a  soft  blowing  sound;  if  the  tube  be  obstructed,  the  sound  will 
have  a  more  or  less  whistling  character,  while,  if  the  obstruction  is  not 
overcome,  air  will  not  be  heard  to  enter  the  middle  ear  at  all  and  the 
sound  wiU  be  distant.  When  the  middle  ear  contains  an  exudate,  the 
sound  will  vary  according  to  the  character  of  the  fluid;  if  it  is  thin 
and  watery,  a  flne  bubbflng  sound  will  be  heard;  if  it  is  thick  and 
\'iscid,  the  sound  wiU  be  a  coarse  bubbling  one.  In  the  presence  of  a 
perforation  of  the  membrana  tympani,  inflation  causes  a  characteris- 
tic hissing  or  whistHng  sound  and  often  secretion  will  be  forced  out 
through  the  perforation  into  the  external  auditory  canal.  By  the  aid 
of  a  speculum,  the  drum  may  be  inspected  and  the  efl'ect  of  the  infla- 
tion upon  it  noted  and  the  mobihty  determined. 

There  are  three  methods  by  which  the  middle  ear  may  be  inflated: 
(i)  Valsalva's  method,  (2)  PoKtzer's  method,  and  (3)  catheteriza- 
tion. Before  practising  inflation  it  is  a  wise  precaution  to  inspect  the 
ear-drum  to  see  if  it  is  suf&ciently  strong  to  stand  the  strain,  as  cases 

364  THE    EAR 

have  been  reported  where  a  diseased  drum  has  been  ruptured  by  the 
Politzer  bag. 

Position  of  Patient. — The  patient  should  be  seated  upon  a  chair. 
The  examiner  is  also  seated,  facing  the  patient. 

Preparations  of  Patient. — In  all  cases  the  nose  and  pharynx  should 
be  thoroughly  cleansed  before  inflation  is  performed  by  means  of 
gargling  and  the  use  of  a  nasal  spray  (page  330). 

Valsalva's  Method. — This  method  of  inflation  is  the  simplest  of 
the  three  and  at  the  same  time  is  the  least  reliable.  It  is  fairly 
successful,  however,  if  only  a  slight  obstruction  exists.  On  account 
of  the  ease  with  which  it  can  be  performed  by  the  patient,  it  is  apt  to 
be  repeated  too  frequently,  wath  the  risk  of  producing  a  flaccid  con- 
dition of  the  drum  unless  the  patient  is  cautioned  against  its  overuse. 

Apparatus. — There  will  be  required  a  head  mirror  and  some 
source  of  illumination,  or  an  electric  head  light,  aural  specula,  and  an 

Fig.  374.. — Aural  stethoscope. 

aural  stethoscope.  The  latter  instrument  (Fig.  374)  consists  of  a 
piece  of  rubber  tubing,  about  3  feet  (90  cm.)  long  into  the  two  ends  of 
which  are  fitted  hard-rubber  ear-pieces — a  white  one  for  the  exam- 
iner's ear  and  a  black  one  to  fit  into  the  patient's  ear. 

Asepsis. — The  specula  and  ear  pieces  of  the  aural  stethoscope 
should  be  sterile. 

Technic. — The  patient's  mouth  should  be  shut  and  the  nostrils 
held  closed  by  the  fingers.  Then  the  patient  is  instructed  to  give  a 
forced  expiration  and  at  the  same  time  swallow.  The  act  of  swallow- 
ing causes  the  tubes  to  relax,  and  the  air,  under  pressure,  is  thus 
forced  through  the  tubes  into  the  middle  ear.  As  this  occurs  the 
patient  will  have  a  feehng  of  distention  in  both  ears,  and  the  exam- 
iner by  means  of  the  aural  stethoscope  will  hear  the  sound  of  air  en- 
tering the  middle  ear.  If  the  drum  membrane  is  inspected  as  the 
inflation  is  performed,  it  will  be  noticed  that  the  membrane  moves 
outward  and  becomes  somewhat  congested. 



Politzer's  Method. — This  is  probably  the  most  frequently 
employed  method  of  inflation. 

Apparatus. — There  will  be  required  a  head  mirror  and  suitable 
illumination  or  an  electric  head  light,  aural  specula,  an  aural  stetho- 
scope, and  a  PoUtzer  air-bag  (Fig.  375).  The  Politzer  air-bag  con- 
sists of  a  soft  pear-shaped  bag  of  such  size  and  shape  that  it  can  be 
readily  compressed  in  the  operator's  hand,  supphed  with  a  piece  of 
rubber  tubing  about  8  inches  (20  cm.)  long,  to  the  end  of  which  is 
attached  an  olive-shaped  glass  nose-piece. 

Asepsis. — The  glass  nose-piece  and  the  specula  should  be  sterilized 
by  boiling  before  use.  The  ear  pieces  of  the  aural  stethoscope  should 
also  be  sterile. 

Technic. — The  patient  is  first  given  a  small  amount  of  water — 
about  a  teaspoonful  is  sufficient — which  he  is  instructed  to  hold  in  his 

Fig.    375. — Instruments  for  Politzer's  method  of  inflation.       i,  Head  mirror;  2, 
aural  specula;  3,  aural  stethoscope;  4,  Politzer  inflation  bag. 

mouth  until  told  to  swallow.  The  examiner  then  inserts  the  nose- 
piece  of  the  PoHtzer  bag  into  one  nostril  for  a  distance  of  about 
1/2  inch  (i  cm.),  and  compresses  both  nostrils  about  it  by  means  of 
the  left  thumb  and  forefinger.  The  patient  is  then  told  to  swallow, 
and,  as  the  larynx  is  seen  to  rise  up  at  the  commencement  of  the  act 
of  swallowing,  the  examiner  compresses  the  air-bag  with  his  right 
hand  (Fig.  376).  The  act  of  swallowing  causes  the  soft  palate  to  rise 
upward  and  shut  oft'  the  naso-pharynx,  and,  at  the  same  time,  the 
Eustachian  tubes  tend  to  open  so  that  the  air  is  readily  forced  through 
the  tubes  into  the  middle  ear.  In  children  crying  has  the  same 
eft'ect  as  swallowing. 

With  the  auscultatory  tube  the  character  of  the  sound  produced 
is  recognized.  When  it  is  desired  to  inflate  only  one  ear,  the  patient's 
head  should  be  turned  to  one  side,  so  that  the  aft'ected  ear  lies  upper- 



most,  while  at  the  same  time  the  opposite  ear  is  closed  by  the  fingers 
pressed  against  the  external  auditory  meatus.  In  using  Politzer's 
bag  care  should  be  taken  not  to  use  a  great  amount  of  force  and 
thereby  avoid  causing  the  patient  pain. 

Catheterization. — Inflation  through  an  Eustachian  catheter  is 
only  indicated  when  inflation  by  the  methods  previously  mentioned  is 
impossible.  The  passage  of  a  catheter  into  the  Eustachian  tube  is  a 
delicate  operation  requiring  skill  as  well  as  gentleness  of  touch  for  its 
safe  and  successful  performance.  If  carelessly  performed,  there  is 
danger  of  injuring  the  mucous  lining  of  the  tube  or  of  making  a  false 
passage  and  injecting  air  into  the  submucous  tissues  of  the  tube,  an 

Fig.  376. — Inflation  by  Politzer's  method. 

accident  from  which  deaths  from  respiratory  obstruction  have  been 
reported.  In  certain  cases  it  may  be  impossible  to  perform  catheteri- 
zation, as,  for  example,  in  the  presence  of  marked  deviations  of  the 
septum,  considerable  narrowing  of  the  nasal  fossae,  tumors,  or  ade- 
noids, and  in  nervous  or  hysterical  individuals  or  in  those  upon  whom 
attempts  to  pass  the  catheter  excite  coughing,  retching,  or  spasm  of 
the  pharyngeal  muscles. 

Apparatus. — There  will  be  required  a  head  mirror  and  suitable 
illumination  or  an  electric  head  Hght,  aural  specula,  an  aural  stetho- 
scope, a  Politzer  air-bag  with  an  Eustachian  catheter  tip,  and  several 
sizes  of  Eustachian  catheters  (Fig.  377).  The  catheter  is  a  metal 
tube  6  1/2  inches  (16  cm.)  long,  curved  at  its  distal  end,  the  extreme 
tip  of  which  is  slightly  bulbous,  and  with  an  expanded  proximal  end 



into  which  the  tip  of  a  PoHtzer  bag  may  be  fitted.  It  should  be  of 
pure  silver  so  that  its  curve  may  be  changed  to  fit  the  individual  case. 
A  ring  is  placed  upon  the  side  of  the  instrument  near  its  proximal 
end  to  indicate  the  direction  of  the  beak.  Three  sizes  should  be  pro- 
vided 1/25,  1/12,  1/8  inch  (i,  2,  and  3  mm.)  in  diameter,  respectively. 

Asepsis. — The  catheter  and  the  specula  should  be  sterilized  by 
boiling;  the  ends  of  the  aural  stethoscope  should  be  likewise  sterile,, 
and  the  hands  of  the  operator  should  be  cleansed  as  for  any  operative 

Anesthesia. — In  sensitive  individuals  the  nose  may  be  anesthe- 
tized by  means  of  a  small  amount  of  a  4  per  cent,  solution  of  cocain 
apphed  by  means  of  a  cotton-tipped  probe  to  the  inferior  meatus. 


Fig.  377. — Instruments  for  inflation  through  an  Eustachian  catheter,  i,  Head 
mirror;  2,  aural  specula;  3,  aural  stethoscope;  4,  Politzer's  inflation  bag;  5,  Eusta- 
chian catheters. 

Technic. — The  operator  fijst  inspects  the  nose  by  the  aid  of 
illumination  for  the  presence  of  deviations  of  the  septum  or  other 
pathological  conditions  which  might  interfere  with  the  passage  of  the 
catheter.     The  catheter  may  then  be  inserted  by  one  of  two  methods : 

I.  Louenherg  Method. — The  proximal  end  of  the  lubricated  cathe- 
ter is  grasped  Hghtly  between  the  thumb  and  forefinger  of  the  right 
hand,  while  by  means  of  the  thumb  of  the  left  hand,  the  tip  of  the 
patient's  nose  is  elevated  so  as  to  straighten  out  the  canal.  The 
beak  of  the  instrument  is  then  introduced  within  the  anterior  nares, 
the  shaft  of  the  instrument  being  in  an  almost  vertical  position  (Fig. 
378).  The  catheter  is  then  elevated  to  a  horizontal  position,  and, 
with  the  tip  kept  constantly  in  contact  with  the  floor  of  the  nose,  it  is 
gently  pushed  inward  until  the  beak  comes  in  contact  mth  the  pos- 
terior wall  of  the  pharynx  (Fig.  379).     The  beak  is  then  rotated 



through  an  angle  of  90  degrees  toward  the  median  line,  until  the  guide 
ring  lies  horizontal,  and  the  catheter  is  drawn  forward  until  its  beak 
is  found  to  impinge  upon  the  nasal  septum  (Fig.  380).     The  beak  is 

Fig.  378. — Catheterizing  the  Eustachian  tube.     First  step,  showing  the  position 
of  the  catheter  for  its  introduction. 

Fig.  379. — Catheterizing    the    Eustachian    tube.     Second    step,    catheter    being 
passed  along  the  floor  of  the  nose. 

then  rotated  downward  and  outward  through  an  angle  of  a  little 
more  than  180  degrees  until  the  guide  ring  points  toward  the  outer 



can  thus  of  the  eye;  at  the  same  time  the  proximal  end  of  the  catheter 
is  moved  toward  the  nasal  septum,  and  its  tip  thus  enters  the  Eu- 
stachian tube  (Fig.  381).     In  all  these  manipulations  care  should  be 

Fig.  380. — Showing  the  different  positions  of  the  beak  of  the  catheter  in  its  in- 
sertion into  the  orifice  of  the  Eustachian  tube.     (After  Barnhill  and  Wales.) 

taken  to  employ  the  greatest  gentleness.  The  entrance  of  the 
catheter  into  the  tube  will  be  recognized  by  the  fact  that  the  tip  is 
firmly  fixed  and   cannot  be  rotated.     The   catheter  is  now  held 

Fig.  381. — Catheterizing  the  Eustachian  tube.     Third  step,  showing  the  position 
of  the  guide  when  the  catheter  tip  is  entering  the  orifice  of  the  tube. 

in  place  by  the  thumb  and  forefinger  of  the  left  hand,  the  other  fin- 
gers resting  upon  the  bridge  of  the  nose,  and,  with  the  nozzle  of  the 
air-bag  fitted  into  the  proximal  end  of  the  catheter,  inflation  is  per- 



formed  by  compressing  the  bag  in  the  fingers  of  the  right  hand  (Fig. 
382).  While  this  is  done  the  examiner  notes  the  sound  produced  by 
means  of  the  auscultation  tube. 

In  removing  the  catheter  it  is  first  rotated  until  its  back  points 
downward  and  is  then  gently  withdrawn  by  a  reversal  of  the  move- 
ments employed  in  its  insertion. 

2.  Binnajont  or  Kramer  Method. — The  instrument  is  introduced 
in  the  same  manner  as  described  under  the  Lowenberg  method  until 
the  beak  is  in  contact  with  the  posterior  pharyngeal  wall.  The 
beak  is  then  rotated  outward  through  more  than  an  angle  of  90  degrees 
which  causes  its  tip  to  rest  in  Rosenmiiller's  fossa.     The  catheter  is 

Fig.  382. — Inflation  through  an  Eustachian  catheter.      (Gleason.) 

then  withdrawn  until  its  tip  is  felt  to  slip  over  the  bulging  posterior 
lip  of  the  Eustachian  mouth  when  its  tip  will  be  at  the  pharyngeal 
orifice  of  the  tube.  The  distance  it  is  necessary  to  withdraw  the 
catheter  to  accomplish  this  varies  usually  between  1/4  to  3/8  inch 
(6  to  9  mm.) .  The  catheter  is  then  rotated  until  the  guide  ring  points 
to  the  outer  canthus  of  the  eye  and  the  tip  slips  into  the  tube.  With 
the  catheter  in  position  inflation  is  performed  as  described  above. 

Therapeutic  Measures 

Syringing  of  the  ear  is  employed  for  the  purpose  of  removing 
foreign  bodies  or  cerumenous  masses  from  the  external  auditory  canal 



and  to  keep  the  ear  free  from  purulent  material  which  collects  after 
perforation  or  incision  of  the  drum  membrane.  In  using  an  ear 
syringe  one  must  always  employ  extreme  gentleness  and  solutions  of 
the  proper  temperature,  otherwise  the  procedure  is  not  only  rendered 
painful,  but  is  capable  of  causing  harm.     Especially  is  it  necessary 

Fig.  383. — Allport's  ear  syringe. 

to  avoid  forcible  injections  in  cases  where  the  tympanum  is  exposed 
through  destruction  of  a  considerable  portion  of  the  drum  membrane. 
The  Syringe. — The  syringe  should  be  simple  in  construction  and 
of  such  material  that  it  may  be  easily  sterilized,  and  should  have  a 
capacity  of  i  or  2  ounces  (30  to  60  c.c).  It  should  be  provided  with 
a  blunt  conical  nozzle — the  ordinary  olive-shaped  tip  is  not  to  be 
commended,  as  it  interferes  with  a  free  return  flow.     A  syringe  with 

Fig.  384. — Metal  ear  syringe  with  a  small  nozzle. 

a  long-pointed  nozzle,  such  as  is  shown  in  Fig.  384,  will  often  be  found 
more  efficacious  in  removing  foreign  bodies  than  the  ordinary 

For  irrigating  the  internal  ear  through  a  perforation  in  the  attic, 
a  smaller  syringe,  such  as  Blake's  (Fig.  385),  with  a  capacity  of  1/2 
dram  (2  c.c),  provided  with  specially  bent  tips,  is  used.  There  will 
be  required,  in  addition,  suitable  illumination,  aural  specula,  and  an 
aural  applicator. 

372  THE   EAR 

Asepsis. — The  syringe  and  nozzle  as  well  as  the  specula  and 
applicator  should  be  sterilized  by  boiling  before  being  used,  and  the 
solution  used  should  be  sterile. 

Solutions  Used. — Normal  salt  solution  (oi  (4  gm.)  of  salt  to  a 
pint  (500  c.c.)  of  boiled  water),  a  saturated  solution  of  boric  acid, 
a  solution  of  bichlorid  of  mercury,  i  to  5000  to  i  to  2000,  are  among 
those  frequently  employed. 

Temperature. — The  solution  should  be  injected  warm — at  about 
a  temperature  of  100°  F.  (t,8°  C).  Cold  solution  should  never  be 
used,  as  it  is  apt  to  cause, vertigo  or  fainting. 

Quantity. — For  the  purpose  of  removing  foreign  bodies  or  wax, 
I  or  2  syringefuls  of  solution  are  usually  sufficient.  When  syringing 
is  employed  in  cases  of  otorrhea,  much  larger  quantities  are  neces- 
sary, as  much  as  1/4  to  i  pint  (125  to  500  c.c.)  being  required  at  a 

Frequency. — This  will  depend  upon  the  virulence  of  the  infection 

Fig.  385. — Blake's  tympanic  .syringe. 

and  the  amount  of  discharge.  When  the  latter  is  very  profuse, 
syringing  may  be  indicated  three  or  four  times  a  day  or  oftener. 

Position  of  Patient. — The  patient  is  seated  with  the  head  held 

Technic. — The  patient's  clothing  is  protected  by  means  of  a  towel 
secured  about  the  neck  and  by  having  him  hold  a  small  glass  basin 
below  the  auricle  to  receive  the  returning  fluid.  The  operator  then 
grasps  the  auricle  between  the  left  thumb  and  forefinger  and  draws  it 
upward  and  backward,  so  as  to  straighten  out  the  external  auditory 
canal.  With  the  right  hand  he  then  introduces  the  nozzle  of  the 
syringe  into  the  external  canal  in  such  a  way  that  the  tip  of  the 
syringe  rests  against  the  superior  wall  of  the  canal,  so  that  the  solu- 
tion, as  it  is  injected,  will  pass  along  the  upper  wall  and  wash. out 
purulent  matter  or  foreign  material  below  (Fig.  386).  The  solution 
is  then  injected  with  only  a  small  amount  of  force  in  sufficient  quanti- 


ties  for  the  purpose  of  the  operation.  Should  dizziness  or  syncope 
supervene,  the  operation  should  be  immediately  stopped. 

At  the  completion  of  the  syringing  all  moisture  is  removed  by 
means  of  a  cotton-tipped  probe  and,  in  the  presence  of  a  discharge,  a 
strip  of  sterile  gauze  is  lightly  placed  in  the  external  canal. 

In  cases  where  it  is  necessary  to  cleanse  out  the  attic  through 
a  perforation,  the  drum  is  exposed  by  the  aid  of  a  speculum  and 
good  illumination,  and  Blake's  angular  cannula  is  inserted  through 

Fig.  386. — Washing  impacted  cerumen  from  canal.     Showing  how  to  hold  auricle 
to  straighten  the  canal  and  where  to  direct  the  stream  of  water.      (Gleason.) 

the  perforation  under  direct  vision.     The  cavity  is  then  carefully 
cleansed  by  gentle  syringing. 


In  some  cases  of  otorrhea  where  the  discharge  has  become  scanty, 
the  long  continued  use  of  douches  often  seems  to  keep  up  an  irritation 
and  a  persistence  of  the  discharge.  In  these  cases  the  instillation  of 
astringent  solutions  for  the  purpose  of  promoting  healthy  granula- 
tions may  be  substituted.  The  solutions  may  be  thus  applied  to  the 
external  auditory  canal  to  affect  the  lining  of  the  canal  or  membrana 
tympani  or  to  the  tympanic  cavity  through  a  perforation  when  the 
latter  contains  unhealthy  granulation  tissue. 

Instruments. — To  instil  a  solution  into  the  external  auditory 
canal,  an  ordinary  glass  medicine  dropper  may  be  employed.     For 



tympanic  instillations  a  pipette  glass  dropper  with  a  small  curved 
tip,  a  head  mirror  and  illumination,  and  an  aural  speculum  will 
be  required  (Fig.  387). 

Fig.  387. — Instruments    for    tympanic  instillation.        i,  Head     mirror;    2,    aural 
specula;  3,  glass  instillator. 


Asepsis. — The  instruments  should  always  be  sterilized  before 
Solutions. — Solutions  of  silver  nitrate  5  to  20  per  cent.,  copper 

Fig.  388. — vShowing  nozzle  of  a  pipette  inserted  for  a  tympanic  instillation. 

sulphate  5  per  cent.,  zinc  sulphate  5  per  cent.,  alcohol  25  to  95  per 
cent,  may  be  used. 

Temperature. — The  solutions  should  always  be  warm — at  about 
100°  F.  (38°  C). 



Position  of  Patient. — The  patient  should  be  seated  with  the  head 
bent  sideways  so  that  the  affected  ear  hes  uppermost. 

Technic. — The  ear  is  first  cleansed  and  all  secretion  or  fluid  re- 
moved by  means  of  a  cotton-tipped  probe.  The  operator  then 
straightens  out-  the  external  auditory  canal  by  grasping  the  auricle 
between  the  thumb  and  forefinger  of  the  left  hand  and  exerting  trac- 
tion in  an  upward  and  backward  direction.  With  the  right  hand  he 
then  instils  5  to  10  drops  (0.3  to  0.6  c.c.)  of  the  desired  solution  into 
the  auditory  canal.  This  is  retained  for  from  five  to  ten  minutes,  or 
for  a  shorter  time  if  it  causes  burning  or  pain,  and  is  then  permitted 
to  escape  by  having  the  patient  incline  the  ear  downward. 

In  making  intratympanic  instillations  the  auditory  canal  is  first 
cleansed  and  the  drum  is  exposed  by  means  of  a  speculum.  The 
point  of  the  pipette  is  then  carefully  inserted  through  the  perforation 
and  a  few  drops  of  weak  solution  are  injected  (Fig.  388). 


The  application  of  chemical  caustics  to  the  ear  may  be  required 
for  the  purpose  of  destroying  granulations  or  small  polypi.     The  most 

Fig.  389. — Instruments  for  applying  caustics  to  the  ear.      i,  Head 
aural  specula;  3,  aural  probe;  4,  applicator. 

mirror;   2, 

frequently  employed  agents  for  this  purpose  are  chromic  acid  or 
silver  nitrate.  They  are  applied  fused  upon  the  tip  of  a  deHcate  ear 
probe.  In  making  such  appHcations  with  strong  chemicals  great 
care  must  be  taken  that  the  caustic  only  comes  in  contact  with  the 

376  THE   EAR 

area  to  be  treated.  They  should,  therefore,  only  be  applied  by  the  aid 
of  a  speculum  and  good  illumination. 

Instruments. — There  will  be  required  a  head  mirror  and  a  source 
of  strong  light,  aural  specula,  a  delicate  aural  probe,  and  an  aural 
applicator  (Fig.  389). 

The  method  by  which  the  acid  or  silver  nitrate  is  fused  upon  the 
probe  has  been  previously  described  (see  page  334). 

Asepsis. — The  instruments  should  be  boiled  before  use. 

Position  of  the  Patient. — The  patient  and  the  operator  are  seated 
in  the  same  relative  positions  as  for  an  ordinary  otoscopic 

Technic. — With  the  speculum  inserted  in  the  ear  and  the  parts 
well  illuminated,  the  site  of  the  intended  application  is  cleansed  and 
then  thoroughly  dried  by  means  of  cotton  wrapped  upon  the  end  of 
an  aural  applicator.  This  is  very  important,  for  if  any  fluid  be  in  the 
ear  the  caustic  will  spread  to  other  parts  as  soon  as  it  is  applied.  The 
caustic  is  then  carefully  applied  to  the  area  it  is  desired  to  destroy. 


The  value  of  inflation  in  diagnosis  has  been  previously  considered 
(see  page  363).  As  a  therapeutic  measure  it  is  employed  in  tubal  and 
middle-ear  disease  with  occlusion  of  the  tube  for  the  purpose  of  re- 
storing the  normal  tension  between  the  drum  membrane,  ossicles, 
and  the  internal  ear.  The  circulation  is  thus  improved  and  hyper- 
emia and  infiltration  of  the  tubal  and  tympanic  mucous  membrane  is 
diminished.  At  the  same  time  morbid  secretions  are  removed  from 
the  Eustachian  tube  and  tympanic  cavity,  and  newly  formed  ad- 
hesions are  broken  down. 

The  methods  by  which  inflation  may  be  performed  and  the  technic 
will  be  found  described  on  page  364. 


In  certain  cases  of  subacute  or  chronic  nonsuppurative  otitis 
media,  inflation  with  medicated  vapors  is  often  employed  to  better 
advantage  than  plain  air.  The  vapor  of  drugs  having  either  a  seda- 
tive or  stimulating  action  may  be  used.  In  this  way  all  the  benefits 
of  inflation  plus  the  sedative  or  stimulating  effect  of  the  vapor  upon 
the  mucous  membrane  are  obtained. 

Apparatus. — A  vaporizer,  in  which  the  air  current  passes  over  the 
volatile  drug  it  is  desired  to  employ,  attached  to  an  Eustachian  cath- 


eter,  forms  the  necessary  apparatus.  There  are  a  number  of  con- 
venient vaporizers,  such  as  Hartmann's,  Pynchon's,  or  Dench's 
(Fig.  390).  The  latter  apparatus  is  especially  useful,  as  plain  air 
or  medicated  vapor  may  be  obtained  by  simply  turning  a  key  on  the 
top  of  the  bottle. 

Asepsis. — The  catheter  should  be  sterilized  by  boiling  before  use. 

Formulary. — Vapors  of  menthol,  camphor,  eucalyptol,  iodin, 
turpentine,  chloroform,  and  ether  alone  or  in  combination  are  most 
frequently  employed. 

Preparation  of  Patient. — Same  as  for  catheterization  (see  page 


Position  of  Patient. — Same  as  for  catheterization  (see  page  364). 
Technic. — The  Eustachian   catheter   is   passed   by   one   of   the 

Pig.  390. — Dench's  vaporizer  and  Eutachian  catheter. 

methods  described  on  pages  367  and  370  and  with  all  the  precautions 
detailed  therein.  Inflation  with  air  is  then  performed  in  order  to 
first  force  out  from  the  tube  any  collection  of  mucus  or  secretion  and 
thus  permit  the  medicated  vapor  to  come  in  contact  with  the  mucous 
membrane.  The  medicated  vapor  is  then  blown  into  the  tympanic 
cavity  in  the  same  manner,  after  attaching  the  vaporizer  to  the 



Direct  medication  of  the  Eustachian  tubes  may  be  used  to  advan- 
tage in  the  treatment  of  middle-ear  catarrh  for  the  purpose  of  lessen- 
ing the  swelling  of  the  mucous  membrane,  and  to  diminish  secretions, 
thereby  rendering  the  tubes  more  permeable.  Weak  astringent 
solutions  are  generally  employed  for  this  purpose,  injected  through  an 
Eustachian  catheter. 



Apparatus. — There  will  be  required  an  Eustachian  catheter,  a 
small  syringe,  graduated  in  drops,  and  provided  with  a  tip  that  will 
fit  into  the  proximal  end  of  the  catheter  (Fig.  391),  and  a  Politzer 

Asepsis. — The  catheter  and  syringe  should  be  boiled,  and  the 
solution  employed  should  be  a  sterile  one. 

Solutions  Used. — lodid  of  potassium  5  gr.  (0.32  gm.)  to  the 
ounce  (30  c.c),  silver  nitrate  2  to  5  gr.  (0.13  to  0.32  gm.)  to  the  ounce 
(30  c.c),  sulphate  of  zinc  i  gr.  (0.065  S^i-)  to  the  ounce  (30  c.c), 
protargol  10  to  50  per  cent.,  bicarbonate  of  soda  2  to  5  gr.  (0.13  to 
0.32  gm.)  to  the  ounce  (30  c.c),  etc.,  may  be  employed. 

Quantity. — About  five  to  ten  drops  (0.3  to  0.6  c.c)  of  the 
selected  drug  are  injected  at  a  time.     If  perforation  of  the  drum 

Fig.  391. — Eustachian  catheter  and  sj^ringe  for  medication  of  the  Eustachian 


exists  more  solution  may  be  safely  used,  but  in  its  absence  small 
amounts  only  are  applicable. 

Preparation  of  the  Patient. — Same  as  for  catheterization  (see 
page  364). 

Position  of  Patient. — Same  as  for  catheterization  (see  page  364). 

Technic. — The  catheter  is  introduced  into  the  tube  by  one  of  the 
methods  described  on  pages  367  and  370  and  the  ear  is  inflated  by  the 
Politzer  bag  to  empty  it  of  secretion.  The  small  syringe  is  then 
charged  with  the  warmed  solution,  and  the  desired  amount  is  slowly 
injected  through  the  catheter.  The  air-bag  is  then  substituted  for 
the  syringe  and  the  solution  is  blown  into  the  tube. 


Eustachian  bougies  are  employed  in  overcoming  tubal  obstruc- 
tions which  will  not  yield  to  inflation  and  for  the  purpose  of  dilating 
tubal  strictures.  In  the  latter  condition,  however,  the  use  of  the 
Eustachian  bougie  is  rarely  curative  if  the  stricture  is  composed  of 
dense  connective  tissue. 


The  bougie  is  passed  into  the  tube  through  a  catheter,  and  it 
should  always  be  inserted  with  the  greatest  care  and  gentleness,  as 
it  is  a  very  easy  matter  to  injure  the  mucous  membrane  with  the  result 
that,  if  inflation  be  immediately  performed,  air  may  be  forced  under 
the  mucous  membrane  through  the  tear  and  cause  emphysema.  It 
is,  therefore,  advisable  to  wait  a  day  or  two  after  passing  the  bougie 
before  inflation  is  attempted.  Care  must  also  be  observed  not  to 
pass  the  bougie  a  greater  distance  than  the  length  of  the  tube;  that 
is,  not  more  than  i  1/4  inches  (3  cm.)  beyond  the  tip  of  the  catheter. 

Fig.    392. — Instruments  for  dilatation  of  the  Eustachian  tubes,      i,  Eustachian 
catheters;  2,  Eustachian  bougies;  3,  Politzer's  inflation  bag. 

Instruments. — There  will  be  required  an  Eustachian  catheter, 
Eustachian  bougies,  and  a  Politzer  air-bag  (Fig.  392).  The  bougies 
are  made  of  silkworm  gut  or  whalebone,  with  tips  conical  or  bulbous 
in  shape,  and  varying  in  diameter  from  1/64  to  1/25  inch  (0.4  mm. 
to  I  mm.).  The  catheter  used  to  guide  the  bougie  into  the  tube 
should  be  somewhat  shorter  than  ordinary  with  a  longer  curved  beak. 

Asepsis. — The  catheters  are  sterilized  by  boiling  and  the  bougies 
by  immersion  in  a  saturated  solution  of  boric  acid. 

Fig.  393. — Showing  the  bougie  inserted  in  the  catheter  ready  to  be  passed  into 

the  Eustachian  tube. 

Frequency, — Bougies  should  not  be  inserted  more  frequently 
than  two  or  three  times  a  week  in  order  to  permit  the  reaction  from 
one  insertion  to  subside  before  another  is  attempted. 

Preparations  of  Patient. — Same  as  for  catheterization  (see  page 


Position  of  Patient. — Same  as  for  catheterization  (seepage  364). 

Technic. — The  bougie  is  lubricated  and  is  introduced  within  the 
catheter  until  the  tip  is  level  with  the  distal  end  of  the  catheter  (Fig. 
393).     The  catheter,  with  the  bougie  in  place,  is  then  introduced 

380  THE   EAR 

into  the  tube  in  the  manner  described  on  page  367.  The  bougie  is 
then  carefully  passed  into  the  tube  for  not  more  than  i  1/4  inches 
(3  cm.)  which  can  be  accomplished  in  a  normal  tube  without  difficulty. 
If  the  bougie  passes  into  the  Eustachian  tube,  the  patient  will  com- 
plain of  some  pain  in  the  ear,  neck,  or  occiput,  whereas,  if  it  doubles 
back  into  the  pharynx,  discomfort  will  be  felt  in  that  region.  When 
resistance  is  encountered,  the  bougie  should  be  pushed  forward 
slowly  and  with  great  caution,  occasionally  rotating  the  bougie; 
forcible  manipulations  must  always  he  avoided  for  fear  of  injuring  the 
mucous  membrane.  Having  successfully  overcome  the  obstruction, 
the  bougie  is  left  in  situ  for  five  to  ten  minutes.  At  the  next  sitting 
a  larger-sized  bougie  is  employed. 

The  Medicated  Bougie, — A  medicated  bougie,  obtained  by  dip- 
ping a  silkworm-gut  bougie  in  some  astringent  solution,  such  as 
silver  nitrate,  before  its  passage,  often  has  more  pronounced  and  more 
prolonged  effect  than  the  plain  bougie  in  overcoming  a  stenosis  due 
to  congestion  or  inflammation  of  the  mucous  membrane.  The 
medicated  bougie  is  introduced  in  the  same  manner  as  an  ordinary 
bougie,  and  should  be  allowed  to  remain  in  place  about  fifteen  to 
twenty  minutes  to  obtain  a  prolonged  action  of  the  astringent. 


Massage  of  the  ear-drum  is  performed  by  alternately  rarefying 
and  condensing  the  air  in  the  external  auditory  meatus.  This  produces 
an  increased  mobility  in  the  membrana  tympani  and  ossicles  with 
the  result  that  adhesive  processes  between  the  drum  membrane  and 
inner  wall  of  the  tympanum  are  avoided  or  broken  up  when  formed 
and  likewise  ankylosis  of  the  ossicular  chain  is  prevented.  The 
method,  therefore,  has  greatest  value  in  adhesive  forms  of  middle-ear 
disease;  in  acute  conditions  its  use  is  contraindicated.  In  all  cases 
an  accurate  diagnosis  is  the  first  essential,  otherwise  massage  may 
result  in  harm.  It  should  be  avoided  in  all  cases  of  relaxed  drum  or 
where  portions  of  the  membrane  are  atrophic.  In  the  latter  condition 
the  atrophied  weakened  portion  will  move  under  the  influence  of 
suction  while  the  rest  of  the  drum  will  be  unaffected. 

Apparatus. — The  massage  is  performed  with  the  Siegle  type  of 
instrument  (see  Fig.  371),  by  means  of  which  the  drum  membrane 
may  be  observed  and  the  effect  of  the  manage  noted. 

Asepsis. — The  speculum  portion  of  the  instrument  should  be 


Duration. — The  massage  may  be  applied  for  one  to  two  minutes 
at  a  sitting. 

Frequency. — Treatments  should  be  given  two  to  three  times  a 
week,  but  only  so  long  as  improvement  in  distance  hearing  takes 

Technic. — The  otoscope  is  introduced  into  the  ear  in  the  manner 
described  on  page  360,  and  the  air  is  alternately  rarefied  and  con- 
densed by  relaxation  or  compression  of  the  bulb.  The  amount  of 
pressure  used  should  be  regulated  by  noting  the  effect  upon  the  mem- 
brane and  ossicles.  If  the  procedure  causes  pain,  the  pressure 
should  be  promptly  reduced. 


Incision  of  the  drum  membrane  should  always  be  promptly  per- 
formed in  otitis  media  when  the  drum  is  bulging,  for  the  purpose  of 
establishing  drainage  for  the  exudate  and  thereby  preventing  necrosis 
of  the  membrana  tympani  and  tympanic  contents.  It  is  also  indi- 
cated in  acute  cases  in  which,  while  the  membrane  is  not  actually 
bulging,  it  shows  marked  hyperemia  and  infiltration  and  the  patient 
suffers  from  severe  pain  and  exhibits  constitutional  symptoms  of  a 
severe  infection.  Especially  in  infants  is  early  incision  required  under 
such  conditions.  If  incision  is  delayed  until  bulging  occurs,  exten- 
sive destructive  changes  may  have  occurred  and  the  process  may 
rapidly  extend  to  the  mastoid  antrum  or  to  the  cranial  cavity. 
Finally,  early  incision  is  always  indicated  if  in  the  course  of  middle- 
ear  disease  there  are  signs  of  mastoid  involvement  or  of  meningitis. 

The  extent  of  incision  is  of  importance.  Simple  puncture,  or 
paracentesis,  is  to  be  avoided;  instead,  the  incision  should  be  of 
sufficient  size  to  afford  free  drainage  for  the  products  of  suppuration, 
varying  according  to  the  age  of  the  individual,  from  1/4  to  3/8  inch 
(6  to  9  mm.)  in  length. 

Instruments. — There  will  be  required  a  head  mirror  and  source 
of  illumination  or  an  electric  head  light,  aural  specula,  a  sharp 
paracentesis  knife  (straight  or  angular),  and  an  ear  syringe   (Fig. 


Asepsis. — The  instruments  should  be  sterilized  by  boiling,  and 
the  operator's  hands  cleansed  as  thoroughly  as  for  any  operation. 

Preparations  of  Patient. — The  external  auditory  canal  should  be 
thoroughly  cleansed  by  syringing  with  warm  saturated  boracic  acid 
solution  or  with  a  i  to  5000  bichlorid  of  mercury  solution. 



Anesthesia. — The  operation  is  quite  painful.  In  children  general 
anesthesia  by  chloroform  is  indicated,  while  in  adults  nitrous  oxid 
gas  or  some  form  of  local  anesthesia  may  be  used.  Local  anesthesia, 
by  means  of  a  solution  of  cocain  applied  to  the  unbroken  mem- 
brane, is  not  satisfactory,  as  the  cocain  is  not  absorbed.  Instead, 
the  following  mixture  may  be  employed: 

T^.     Cocain  hydrochlorate,  gr.  vi  (0.4  gm.) 

Anilin  oil, 
Alcohol,  aa  3i  (4  c.c.) 

A  small  amount  of  this  solution  is  instilled  into  the  external  auditory 
canal  and  is  allowed  to  remain  for  lifteen  minutes.     It  must  be  used 

Fig.  394. — Instruments  for  incising  the  drum  membrane,     i,  Head  mirror;  2, 
aural  specula;  3,  angular  paracentesis  knife;  4,  Allport's  ear  syringe. 

with  great  care  if  a  perforation  be  present,  as  it  will  thus  enter  the 
tympanic  cavity  where  absorption  is  rapid  and  toxic  symptoms  may 

Technic. — The  drum  is  exposed  by  means  of  a  speculum  under 
good  illumination,  and  the  external  canal  is  thoroughly  dried.  The 
knife  is  then  inserted  through  the  membrane  in  the  postero-inferior 
quadrant,  and  the  posterior  quadrant  of  the  drum  is  incised  in  a 
curve  upward  to  the  tympanic  vault  (Fig.  395).  In  doing  this,  the 
knife  should  only  be  inserted  through  the  drum  membrane,  so  as  to 
avoid  injuring  the  inner  tympanic  wall  which  lies  distant  1/12 
to  1/6  inch  (2  to  4  mm.).     Of  course,  if  there  is  any  localized  bulg- 



Fig.  395. — Incision  of  the  membrana  tympani  in  acute  otitis  media  involving  the 
lower  portion  of  the  tympanic  cavitj*.      (Dench.j 

Fig.  396. — Incision  of  the  membrana  tA^mpani  in  acute  otitis  media,  involving  the 
upper  portion  of  the  tympanic  cavitj'.     (Dench.) 

384  THE   EAR 

ing,  the  incision  should  be  so  placed  as  to  relieve  it.  When  the  tym- 
panic vault  alone  is  involved,  the  knife  is  entered  in  the  posterior 
quadrant  opposite  the  short  process  of  the  malleus  and  the  incision 
is  carried  upward  through  Shrapnell's  membrane.  The  knife  is  then 
turned  backward,  and,  as  it  is  wTithdrawn,  the  tissues  of  the  posterior 
wall  of  the  auditory  canal  are  incised  down  to  the  bone  for  a  distance 
of  about  1/8  inch  (3  mm.)  from  the  drum  (Fig.  396).  In  this  way 
tension  in  the  tympanic  vault  and  mastoid  is  relieved. 

The  ear  is  then  carefully  cleansed  by  syringing  and,  after  being 
well  dried,  is  loosely  packed  with  gauze. 

After-treatment. — The  ear  should  be  syringed  with  a  warm  i  to 
5000  bichlorid  of  merciiry  solution  as  often  as  secretion  collects.  At 
first,  this  will  necessitate  syringing  every  two  or  three  hours.  As  the 
discharge  decreases,  longer  intervals  may  elapse. 


Anatomic  Considerations 

The  larynx  is  that  portion  of  the  upper  air  passages  extending 
between  the  base  of  the  tongue  and  the  trachea.  It  lies  in  the  median 
line  of  the  neck,  opposite  the  fourth,  fifth,  and  sixth  cervical  verte- 
brae. Anteriorly,  it  is  practically  subcutaneous;  posteriorly,  it 
forms  part  of  the  anterior  boundary  of  the  pharynx;  while  on  either 
side  of  it  lie  the  great  vessels  of  the  neck.  Above,  it  is  broad  and 
triangular  in  shape,  while  below  it  is  narrow  and  cylindrical. 

The  framework,  consisting  of  a  number  of  cartilages  held  together 
by  ligaments,  is  lined  with  mucous  membrane,  and  is  capable  of 
being  moved  by  muscles  which  change  the  relative  positions  of  the 
cartilages  and  thus  modify  the  approximation  of  the  vocal  cords 
during  respiration  and  phonation.  The  most  important  of  these 
cartilages  are  the  thyroid,  the  epiglottis,  the  cricoid,  and  the  two 

The  thyroid  cartilage  is  the  largest  of  all,  and  consists  of  two 
broad  lateral  alas  joined  in  front  at  an  acute  angle.  Above,  it  is 
joined  to  the  hyoid  bone  by  the  thyrohyoid  membrane,  and,  below,  to 
the  cricoid  cartilage  by  the  cricothyroid  membrane.  The  space 
between  the  thyroid  and  cricoid  cartilages  in  an  adult  measures 
about  half  an  inch  (i  cm.)  in  height;  an  opening  made  through  this 
space  gives  easy  access  to  the  larynx  below  the  vocal  cords. 

The  epiglottis  is  a  leaf-shaped  piece  of  elastic  cartilage  i  1/3  inches 
(3.5  cm.)  long,  guarding  the  superior  entrance  of  the  larynx.  It  is 
attached  by  its  stalk  to  the  upper  and  posterior  aspect  of  the  angle 
between  the  thyroid  alae  and  to  the  hyoid  bone  by  ligaments.  It 
lies  directly  behind  the  tongue,  and  in  swallowing  it  is  pushed  back- 
ward by  the  bolus  of  food,  closing  more  or  less  completely  the  laryn- 
geal opening  and  thereby  preventing  the  entrance  of  food  into  the 

The  cricoid    cartilage  is  a    small,   nearly  semicircular   cartilage 
forming  the  lower  part  of  the  cavity  of  the  larynx.     It  is  narrow  in 
front,  but  becomes  broadened  and  high  posteriorly.     Upon  its  supe- 
rior border  on  either  side  it  supports  the  arytenoid  cartilages. 
25  385 



The  arytenoid  cartilages,  two  in  number,  are  irregularly  pyram- 
idal in  shape  and  rest  by  their  bases  on  the  superior  border  of  the 
cricoid  cartilage.  They  rotate  upon  a  vertical  axis  and  also  move 
laterally.  Through  these  movements  the  vocal  cords  are  approxi- 
mated or  drawn  apart. 

The  Interior  of  the  Larynx. — The  superior  opening  is  wide  and 
semicircular  in  front  where  it  is  bounded  by  the  epiglottis.  The 
sides  are  formed  by  the  arytenoepiglottic  folds  of  mucous  membrane 
which  run  from  the  sides  of  the  epiglottis  to  the  tops  of  the  arytenoid 
cartilages  and  gradually  approach  posteriorly,  so  that  the  opening  is 

Fig.  397. — Anterior  view  of  the  larynx.  (After  Deaver.)  i,  Epiglottis;  2, 
lesser  cornu  of  hyoid  bone;  3,  greater  cornu  of  hyoid  bone;  4,  thyrohyoid  mem- 
brane; 5,  thyroid  cartilage;  6,  cricothyroid  membrane;  7,  cricoid  cartilage;  8, 

narrowed  behind.  More  or  less  distinct  nodular  prominences 
formed  by  the  cuneiform  and  corniculate  cartilages  are  recognized 
on  these  folds. 

The  cavity  of  the  larynx  extends  from  the  superior  aperture  to 
the  lower  border  of  the  cricoid  cartilage.  It  is  divided  into  two  por- 
tions by  the  vocal  cords — above,  into  the  supraglottic  region,  and, 
below,  into  the  subglottic  region.  The  vocal  cords  consist  of  two 
delicate  bands  of  elastic  tissue  enclosed  in  thin  layers  of  mucous  mem- 
brane having  a  whitish  appearance.  They  are  attached  anteriorly 
to  the  thyroid  cartilage  and  posteriorly  to  the  arytenoids.  They 
measure  about  3/4  inch  (2  cm.)  in  length  in  the  male,  and  1/2  inch 
(i  cm.)  in  the  female.     Between  the  two  cords  is  a  long  narrow 



chink,  the  glottis.  Above  and  parallel  to  the  vocal  cords  are  two 
second  folds  of  mucous  membrane  enclosing  ligamentous  tissue,. 
attached  to  the  thyroid  cartilage  in  front  and  to  the  two  arytenoids 
behind,  commonly  called  the  false  vocal  cords.  Lying  between  the 
vocal  cords  and  these  two  bands  are  two  oblong  fossae,  the  ventricles 
of  the  larynx. 

The  mucous  membrane  of  the  larynx  is  continuous  above  with 
that  lining  the  pharynx,  and  below  with  that  of  the  trachea  and  bron- 
chi. It  is  of  the  columnar  ciliated  variety,  excepting  where  it  covers 
the  vocal  cords  and  the  space  above  the  vocal  cords,  in  which  regions 
it  is  of  the  stratified  variety.  It  contains  many  mucous  glands,  espe- 
cially numerous  upon  the  epiglottis. 

Fig.  398. — The  interior  of  the  larynx,  i,  Epiglottis;  2,  thyroid  cartilage;  3, 
ventricle  of  larynx;  4,  cricoid  cartilage;  5,  false  vocal  cords;  6,  vocal  cords;  7, 
first  ring  of  trachea. 

The  trachea  is  a  cylindrical  tube,  composed  of  cartilages  and 
membrane,  extending  from  the  cricoid  cartilage,  at  the  level  of  the 
sixth  cervical  vertebra,  to  a  point  opposite  the  fourth  dorsal,  where  it 
divides  into  a  right  and  left  bronchus.  It  is  from  4  to  4  3/4  inches 
(10  to  12  cm.)  long  in  males,  and  from  3  2/3  to  4  1/2  inches  (9  to  11 
cm.)  long  in  females.  Its  transverse  diameter  measures  on  an 
average  4/5  of  an  inch  (2  cm.)  in  males,  and  less  in  females.  In  a 
child  of  from  two  to  four  years,  the  transverse  diameter  measures 
1/3  of  an  inch  (8  mm.) ;  in  a  child  under  eighteen  months,  it  measures 
1/4  of  an  inch  (6  mm.). 

The  framework  of  the  trachea  is  composed  of  from  sixteen  to 



nineteen  rings  of  hyaline  cartilage,  incomplete  behind,  each  measur- 
ing 1/12  to  1/5  of  an  inch  (2  to  5  mm.)  in  breadth.  The  narrow 
space  between  these  rings  is  filled  with  an  elastic  fibrous  membrane 
which  splits  into  two  layers  to  enclose  each  cartilage,  and  also 
serves  to  complete  the  tube  posteriorly.  Internally,  the  trachea  is 
lined  with  a  smooth  mucous  membrane  of  the  ciliated  variety,  con- 
tinuous above  with  that  of  the  larynx  and  below  with  that  of  the 
bronchi.  It  contains  an  abundance  of  lymphoid  tissue  and  mucous 
glands.  ♦ 



Inf.  thyr.  art. 

iXi'yfif' Comnte>v^  ^^^         '    '^^^  ij-'S^  — " 



/.eft  Jube/avian, 

Fig.  399. — Anatomy  of  the  trachea  and  its  relations. 

The  trachea  lies  in  a  mass  of  loose  fat  which  permits  free  motion 
upward,  downward,  and  horizontally.  In  its  upper  part  it  lies  com- 
paratively superficial,  but  becomes  more  deeply  placed  as  it  ap- 
proaches the  thorax.  The  isthmus  of  the  thyroid  gland  lies  opposite 
the  second  and  third  rings;  below  this  the  following  structures  will 
be  met  from  above  downward:  the  inferior  thyroid  veins,  the  arteria 
thyroidea  ima  (if  present),  the  sternohyoid  and  sternothyroid  mus- 
cles, the  cervical  fascia,  an  anastomosis  of  the  anterior  jugular  veins; 
and  in  the  thorax,  the  remains  of  the  thymus  gland,  the  left  innomi- 


nate  vein,  the  arch  of  the  aorta,  and  the  innominate  and  the  left 
common  carotid  arteries.  Behind  hes  the  esophagus.  Laterally, 
the  trachea  is  in  relation  with  the  common  carotid  arteries,  the 
lateral  lobes  of  the  thyroid,  the  inferior  thyroid  arteries,  and  the  re- 
current laryngeal  nerves.  These  relations  are  important  to  bear  in 
mind  in  performing  tracheotomy. 

Diagnostic  Methods 

The  diagnostic  methods  employed  in  connection  with  the  larynx 
and  trachea  consist  in  (i)  inspection  by  means  of  a  laryngeal  mirror, 
(2)  direct  inspection  through  endoscopic  tubes,  (3)  palpation  by  the 
probe  or  finger,  and  (4)  skiagraphy. 

As  a  preliminary  to  the  actual  local  examination,  attention 
should  first  be  given  to  the  general  condition  of  the  patient,  and  the 
history  of  other  affections  that  may  have  a  bearing  upon  the  condi- 
tion should  be  inquired  into.  This  is  important,  for,  while  the  symp- 
toms of  processes  involving  this  portion  of  the  respiratory  tract  are 
characteristic  (consisting  of  cough,  dyspnea,  aphonia  or  dysphonia, 
dysphagia,  etc.),  and  as  a  rule  clearly  indicate  the  seat  of  the  trouble, 
it  should  be  borne  in  mind  that  many  of  these  symptoms  are  second- 
ary to  other  conditions,  such  as  gout,  diphtheria,  rheumatism, 
diabetes,  nephritis,  tuberculosis,  syphilis,  diseases  of  the  nervous 
system,  etc.  Thus  it  becomes  of  the  utmost  importance  to  examine 
other  organs  as  well  and  not  to  hmit  the  investigation  to  the  affected 
region  alone. 

Having  completed  this  portion  of  the  examination,  external  in- 
spection and  palpation  of  the  parts  should  be  performed.  In  this 
way  the  presence  of  inflammation,  sweUings,  new  growths,  enlarged 
glands,  fractures  of  the  cartilages,  etc.,  may  be  determined,  and  the 
mobility  or  fixation  of  the  parts  during  swallowing  and  respiration 
may  be  noted. 


By  this  method  the  interior  of  the  larynx  and  trachea  are  in- 
.  spected  by  means  of  a  laryngoscopic  mirror  and  reflected  light.  The 
technic  is  not  diihcult,  and,  if  properly  carried  out,  a  satisfactory  in- 
spection of  the  tissues  may  be  made  as  far  as  the  true  vocal  cords, 
and  under  favorable  conditions  the  region  beyond  the  glottis  as  far 
as  the  subdivision  of  the  trachea  may  also  be  explored,  and  foreign 



bodies  or  pathological  conditions  recognized.  Such  examination  is 
best  made  before  a  meal,  as,  otherwise,  retching  and  vomiting  may  be 

Instruments  and  Apparatus. — Requisites  for  an  ordinary  laryngo- 
scopic  examination  are:  a  strong  light,  such  as  is  obtained  from 
a  Welsbach  burner  covered  by  a  Mackenzie  condenser;  a  concave  head 
mirror,  3  1/2  to  4  inches  (9  to  10  cm.)  in  diameter  with  a  central 
perforation  for  the  eye;  laryngeal  mirrors  of  three  sizes,  1/2,  i,  and 
I  1/2  inches  (i,  2.5,  and  4  cm.)  in  diameter,  that  they  may  be 
adapted  to  the  size  of  the  individual  fauces;  and  an  alcohol  lamp 
(Fig.  400).     The  light  should  be  placed  upon  a  suitable  bracket, 

Fig.  400. — Instruments  for  laryngoscopy.     I,  Laryngeal  mirrors;  2,  head  mirror; 

3,  alcohol  lamp. 

that  it  may  be  raised  or  lowered  to  any  desired  height  (see  Fig.  310). 

Asepsis. — The  laryngeal  mirrors  should  be  sterilized  by  immersion 
in  a  I  to  20  solution  of  carbolic  acid,  then  rinsed  off  in  sterile  water 
and  dried  before  use. 

Position  of  Patient  and  Examiner. — To  obtain  the  best  results, 
the  examination  should  be  performed  in  a  partially  darkened  room. 
The  patient  sits  in  a  straight-backed  chair  with  the  head  raised  and 
inclined  slightly  backward.  The  light  is  located  upon  the  patient's 
right,  a  little  behind  him  and  about  on  a  level  with  the  ear.  The 
operator  sits  facing  the  patient,  with  his  knees  to  one  or  the  other 
side  of  the  patient's,  and  with  his  eye  on  a  level  with  the  patient's 



mouth,  at  a  distance  of  about  a  foot  (30  cm.),  or  the  focal  length  of 
the  mirror. 

Anesthesia. — Ordinarily,  cocainization  of  the  parts  is  unneces- 

FiG.  401. — Laryngoscopy.     First   step,    showing   the   method   of   grasping   the 


sary,  but,  where  the  mucous  membrane  of  the  pharynx  is  very  sen- 
sitive, brushing  a  4  per  cent,  solution  of  cocain  over  the  posterior 
pharyngeal  wall  and  soft  palate  may  be  required  before  a  satisfactory 
examination  is  possible. 

Fig.  402. — Laryngoscopy.     Second  step,  heating  the  mirror. 

Technic. — The  operator  places  himself  and  patient  in  the  proper 
positions,  and  adjusts  the  head  mirror  over  the  left  eye  in  such  a 
manner  that  the  light  will  be  reflected  in  a  circle  upon  the  mouth  of 



the  patient.  The  patient  is  then  directed  to  protrude  the  tip  of  the 
tongue,  which  is  surrounded  with  a  piece  of  clean  gauze  or  small 
napkin  and  is  grasped  between  the  thumb  and  forefinger  of  the  opera- 
tor's left  hand  (Fig.  401).     Light  traction  is  made  outward  and  sightly 

FiG.  403. — Showing  the  method  of  holding  the  mirror. 

upward  rather  than  downward,  so  as  to  avoid  forcing  the  under  sur- 
face of  the  tongue  against  the  lower  incisor  teeth.  The  laryngeal 
mirror  is  then  warmed  to  avoid  condensation  of  moisture  upon  its 
reflecting  surface,  by  holding  it  at  a  httle  distance  above  a  flame  for  a 

Fig.  404. — Laryngoscopy.     Third  step,   showing  the  mirror  being  introduced 
and  also  the  relative  position  of  the  patient  and  examiner  and  the  position  of  the 

few  seconds  (Fig.  402),  the  precaution  being  taken  to  test  the  temperature 
of  the  mirror  before  introducing  it  into  the  mouth;  this  is  determined 
by  bringing  the  back  of  the  mirror  in  contact  with  the  back  of  the 
operator's  hand.     To  introduce  the  mirror,  it  should  be  held  lightly 



between  the  thumb  and  forefinger  of  the  right  hand  with  its  reflect- 
ing surface  downward  (Fig.  403),  and  should  be  made  to  follow  the 
curve  of  the  hard  palate  until  its  back  touches  the  uvula  and  soft 
palate.  It  is  then  pushed  upward  and  backward,  raising  the  uvula 
as  far  out  of  the  way  as  possible.  Care  must  be  taken  in  performing 
this  maneuver  to  avoid  touching  the  base  of  the  tongue,  and,  when 
the  mirror  is  in  position,  to  keep  it  held  steadily  in  place  so  as  not  to 
excite  gagging  or  retching.  Should  this  accident  occur,  the  mirror 
must  be  removed  and  sufficient  time  must  be  allowed  for  the  patient 
to  recover  his  breath  and  the  irritabiHty  to  subside  before  it  is  rein- 

FiG.  405.— Lan-ngoscopy.     Fourth  step,   showing  the  mirror  in  place. 

(J.  U.  Anders.) 

troduced.  As  soon  as  the  instrument  is  in  proper  position,  the 
handle  is  moved  to  one  side  of  the  patient's  mouth  so  as  to  be  well 
out  of  the  line  of  vision.  The  mirror  is  then  slowly  and  gently  turned 
until  a  view  of  the  base  of  the  tongue  is  obtained,  and  any  abnor- 
malities of  the  organ  are  noted;  it  is  then  rotated  in  such  a  manner 
that  its  face  looks  downward  and  the  larynx  is  brought  into  view 
(Fig.  405). 

It  should  be  remembered  that  the  laryngeal  image  ^dll  be  in- 
verted— that  is,  the  structures  of  the  front  part  of  the  larynx  appear 



on  the  upper  part  of  the  mirror,  and  vice  versa;  the  right  and  left 
sides  of  the  laryngeal  image,  of  course,  correspond  to  the  same  sides 
of  the  patient.  In  a  normal  case,  the  following  are  noted:  at  the 
upper  part  of  the  picture,  the  saddle-shaped  epiglottis  of  a  yellowish 
color  traversed  by  its  pink  blood-vessels;  extending  backward  across 

Fig.  406.  Fig.  407. 

Fig.  406. — The  laryngoscopic  image.  I,  Epiglottis;  2,  false  vocal  cords;  3, 
vocal  cords;  4,  glossoepiglottic  fossa;  5,  interarytenoid  space;  6,  cartilage  of  San- 
torini  and  the  location  of  the  arytenoid  cartilage;  7,  cartilage  of  Wrisberg. 

Fig.  407. — The  larynx  during  gentle  respiration. 

the  mirror  back  of  the  epiglottis  are  a  pair  of  pearly-white  bands, 
the  vocal  cords;  parallel  to  the  vocal  cords,  but  lying  anteriorly  and 
outside,  are  a  second  pair  of  bands  with  a  reddish  hue,  the  ventric- 
ular bands,  or  false  vocal  cords;  between  the  vocal  cords  and  the 
ventricular  bands  may  be  observed  the  ventricles  of  the  larynx, 
brought  into  better  view  if  the  head  is  tilted  to  the  side;  where  the 

Fig.  408. — The     larynx    in     phonation. 

Fig.  409. — The    larynx    during    deep 

vocal  cords  terminate  at  the  lower  part  of  the  image  are  to  be  seen 
the  arytenoid  cartilages,  and  between  them  the  interarytenoid  space; 
extending  from  either  side  of  this  notch  to  join  the  epiglottis  are  the 
aryepiglottic  folds,  with  the  two  prominences  marking  the  site  of  the 
cartilages  of  Wrisberg  and  Santorini,  the  latter  lying  on  top  of  the 


arytenoid  cartilages;  on  either  side  of  the  image  will  be  noted  the 
glossoepiglottic  fossee. 

To  make  a  complete  examination,  the  larynx  should  be  inspected 
during  quiet  respiration,  deep  respiration,  and  phonation.  During 
respiration  the  vocal  cords  are  seen  to  move  with  each  expiration 
toward  the  median  line,  and  away  from  the  median  line  with  inspira- 
tion (Fig.  407).  By  requesting  the  patient  to  say  "ee"  or  "he,"  a 
view  is  obtained  of  the  larynx  with  the  cords  almost  in  apposition  and 
the  interarytenoid  space  obhterated  (Fig.  408).  During  deep  respi- 
ration the  cords  are  widely  separated,  and  a  view  is  obtained  of  the 
anterior  wall  of  the  region  below  the  vocal  cords  (Fig.  409).  There 
will  be  seen  the  broad  yellow  cricoid  cartilage  and  the  yellowish  car- 
tilaginous rings  of  the  anterior  wall  of  the  trachea  with  the  interven- 
ing red  membranous  portion.  By  tilting  and  carefully  adjusting  the 
mirror,  the  bifurcation  of  the  trachea  and  the  openings  of  the  two 
bronchi  may  be  brought  into  view.  To  obtain  the  most  favorable 
position  for  inspection  of  the  trachea,  the  patient's  neck  should  be 
held  straight  and  the  chin  extended  somewhat  forward.  The  mirror 
will  also  require  a  different  adjustment,  being  held  more  horizontally 
than  for  laryngoscopy,  and  the  surgeon  should  be  seated  lower. 

The  diseases  that  may  affect  this  portion  of  the  respiratory  tract 
are  not  different  from  what  one  would  find  in  other  regions  com- 
posed of  the  same  tissues.  The  examiner  should  accordingly  first 
note  the  color  of  the  various  parts  brought  to  view  for  signs  of  con- 
gestion or  inflammation,  bearing  in  mind  that  if  cocain  has  been  em- 
ployed the  parts  will  appear  anemic,  and  that  gagging  or  retching 
may  be  responsible  for  congestion.  He  should  look  for  the  presence 
of  exudations,  foreign  bodies,  and  any  structural  changes,  such  as 
ulcerations,  swellings,  abscesses,  edema,  new  growths,  malforma- 
tions, and  dislocations  of  the  arytenoid  cartilages,  etc.  Finally,  the 
condition  and  mobility  of  the  vocal  cords  during  respiration  and 
phonation  are  observed.  They  should  approximate  symmetrically  in 
the  mid-fine  during  phonation,  and  separate  equaUy  with  inspiration. 
The  whole  examination  should  be  made  as  rapidly  as  possible,  not 
more  than  half  a  minute  or  so  being  consumed,  to  avoid  tiring  the 
patient  and  inducing  an  irritable  state  of  the  parts.  Since  often  only 
a  glimpse  of  the  various  structures  may  be  thus  obtained,  it  may  be 
necessary  to  make  more  than  one  inspection  before  the  whole  ex- 
amination is  completed  in  a  satisfactory  manner. 

Difficulties  in  Laryngoscopy. — It  is  sometimes  a  difiScult  matter 
for  a  beginner  to  inspect  the  parts,  owing  to  faulty  technic  or  to 


structural  peculiarities.  A  view  of  the  larynx  may  be  missed  entirely 
through  an  improper  adjustment  of  the  light,  faulty  position  of  the 
patient's  head,  or  holding  the  mirror  at  a  wrong  angle.  Clumsy 
and  hasty  introduction  of  the  mirror,  the  use  of  a  mirror  too  hot  or 
too  cold,  or  rough  traction  on  the  tongue,  all  militate  against  success. 
In  some  cases  an  excessive  irritability  of  the  pharynx  precludes  a 
successful  examination  without  preliminary  cocainization.  In  other 
cases  the  presence  of  enlarged  tonsils  may  prevent  a  good  view  of  the 
parts.  If  such  a  condition  is  present,  a  small  oval  mirror  should  be 
substituted.  A  large  pendulous  epiglottis  is  not  infrequently  a  cause 
of  difficulty.  By  placing  the  mirror  close  to  the  posterior  pharyn- 
geal wall  and  holding  it  more  nearly  vertical  than  usual,  with  the 
patient's  head  thrown  back,  a  better  view  may  often  be  obtained. 

In  young  children  considerable  difficulty  may  be  encountered. 
It  is  best  to  wrap  the  child  in  a  sheet  so  that  the  arms  are  restrained, 
and  to  have  it  held  upon  the  lap  of  an  assistant,  who  also  steadies 
the  child's  head.  A  tongue  depressor  with  a  curved  tip  should  be 
employed  to  hold  the  tongue  forward,  and,  if  necessary,  a  mouth-gag 
may  be  inserted  between  the  teeth.  A  small  laryngeal  mirror  is 
then  introduced,  and  the  examination  is  mg-de  in  the  usual  way.  If 
carefully  and  gently  performed,  a  satisfactory  examination  may 
often  be  made  even  upon  unruly  children. 


The  larynx  and  portions  of  the  air  passages  beyond  may  be  exam- 
ined under  direct  vision  either  by  the  aid  of  illuminated  tubes  or  by 
means  of  a  suitable  tongue  depressor  and  illumination  from  a  head 
light,  the  latter  a  method  designated  by  Kirstein  as  autoscopy.  The 
parts  inspected  in  this  manner  appear  more  nearly  normal  as  to  posi- 
tion and  color  than  when  a  laryngeal  mirror  is  employed.  Further- 
more, foreign  bodies  and  new  growths  may  be  removed,  and  applica- 
tions made  to  diseased  areas  under  direct  vision.  The  method  may 
be  employed  in  young  children  upon  whom  ordinary  laryngoscopy  is 
difficult,  and  it  may  also  be  performed  upon  a  patient  under  general 
anesthesia.  It  is,  however,  more  uncomfortable  for  the  conscious 
patient  than  ordinar}'  laryngoscopy. 

Instruments. — A  tubular  spatula,  self-illuminated,  such  as  Jack- 
son's (Fig.  410),  or  with  the  illumination  furnished  from  an  electric 
head  light,  as  Killian's,  is  generally  employed.  Kirstein  uses  a 
tongue  depressor  of  special  shape  (Fig.  411)  and  an  electric  head 



light  (Fig.  412).    In  addition  a  mouth-gag  and  a  Sajous  applicator 
are  required  (Fig.  413). 

Fig.  410. — Jackson's  self-illuminated  tube  spatula  for  direct  laryngoscopy. 

Asepsis, — The  tubes  and  tongue  depressor  may  be  boiled,  while 
the  light-carrying  apparatus  in  the  self-illuminated  tube  is  sterilized 
by  immersion  in  alcohol. 

Position  of  the  Patient. — The  patient  is  seated  on  a  low  stool  with 
the  upper  part  of  the  body  bent  slightly  forward  and  with  the  head 
raised  and  thrown  back  so  that  a  direct  view  from  above  downward 

Fig.  411. — Kirstein's  tongue  depressor. 

is  possible.  An  assistant  stands  or  sits  behind,  supporting  the 
patient's  head,  and  holding  the  mouth-gag  in  proper  position.  The 
operator  stands  in  front. 

A  child  should  be  seated  upon  the  lap  of  a  nurse,  who  encircles 
its  body  with  her  arms,  confining  the  child's  arms  closely  to  its  sides 
and  clasping  its  legs  between  her  knees.     The  child's  head  rests  upon 



the  nurse's  shoulder,  being  held  in  the  proper  position  from  behind 
by  an  assistant. 

Anesthesia.— Cocainization  of  the  parts  is  usually  necessary  to 
avoid  unpleasant  gagging  and  retching.  This  is  accomphshed  by 
tlie  application  to  the  larynx  and  neighboring  parts  of  a  4  per  cent, 
solution  of  cocain  by  means  of  a  cotton  swab  held  by  a  Sajous  appli- 
cator.    This  should  be  performed  by  the  aid  of  a  laryngeal  mirror. 

Fig.  412. — Kirstein's  head  light. 

If  operative  procedures  are  required,  the  application  of  20  per  cent, 
solution  of  cocain  should  follow  the  preHminary  cocainization.  In 
young  children  the  examination  may  be  carried  out  under  general 

Technic. — The  operation  should,  when  possible,  be  performed 
when  the  stomach  is  empty,  as,  otherwise,  retching  may  result  in 
regurgitation  of  the  stomach  contents.     The  parts  having  been  cocain- 

FiG.  413. — Sajous'  applicator  and  mouth-gag. 

ized,  and  with  the  patient  seated  in  the  proper  position,  a  mouth-gag 
is  inserted  in  one  side  of  the  mouth  and  is  held  in  place  by  the 
assistant  who  supports  the  head.  With  the  lamp  at  the  end  of  the 
instrument  properly  lighted,  if  a  self-illuminated  spatula  is  employed, 
or  with  the  head  lamp  lit  and  adjusted  so  as  to  throw  the  light  into 
the  mouth,  if  a  nonilluminated  tube  is  used,  the  tubular  speculum  is 



introduced  past  the  base  of  the  tongue  until  the  epiglottis  appears. 
Its  tip  is  passed  to  a  point  about  1/2  inch  (i  cm.)  below  the  free  edge 
of  the  epiglottis,  which  is  then  drawn  forward,  and  with  it  the  base 
of  the  tongue  out  of  the  line  of  vision  by  exerting  pressure  upon  the 
handle  of  the  instrument  in  an  upward  and  backward  direction 
(Fig.  414). 

The  operator  then  inspects  the  larynx  by  looking  down  the  tube. 
The  arytenoid  cartilages,  vocal  cords,  interior  of  the  larynx,  and  por- 
tions of  the  trachea  may  thus  be  viewed  in  detail.  The  points  espe- 
cially to  be  noted  in  such  examination  have  already  been  referred  to 

piG.  414. — Direct  laryngoscopy  with  Jackson's  self-illuminated  spatula.  (Modi- 
fied from  Ballenger,)  a.  Electric  cord  supplying  lamp  of  speculum;  b,  conduit  for 
light  carrying  tube;  c,  shows  the  tube  holding  the  epiglottis  forward;  d,  conduit 
for  removing  secretions,  etc.,  by  aspiration  during  the  examination. 

under  laryngoscopy.  By  the  aid  of  these  tubes,  applications  may 
also  be  made,  if  desired,  to  diseased  areas,  and  growths  may  be  re- 
moved by  means  of  delicate  instruments  of  special  design. 

Under  the  method  designated  by  Kirstein  as  autoscopy,  the 
patient  is  placed  in  the  same  position  as  above,  the  mouth  is  illumi- 
nated from  the  electric  head  light,  and  the  special  tongue  depressor 
is  gently  introduced  behind  the  tongue  until  its  tip  rests  between  the 
epiglottis  and  the  base  of  the  tongue.  By  elevating  the  handle  of 
the  instrument,  the  base  of  the  tongue  is  drawn  downward  and  for- 
ward, and  the  epiglottis  is  raised,  so  that  a  groove  is  formed  along 


the  back  of  the  tongue.  With  the  head  light  properly  adjusted  the 
operator  looks  down  this  groove  and  inspects  the  larynx.  The 
posterior  walls  of  the  larj-nx  and  trachea  are  clearly  viewed  by  this 
method,  but  the  anterior  parts  are  not  seen  so  well  as  with  the 
laryngoscopic  mirror. 


In  1897  Killian  devised  long  endoscopic  tubes  that  could  be  intro- 
duced through  the  mouth  or  through  a  tracheotomy  wound,  with 
which  the  trachea  and  bronchi  may  be  examined  by  the  aid  of  illu- 
mination from  an  electric  head  light.  This  operation  is  designated 
respectively  as  "upper  direct  tracheo-bronchoscopy,"  and  "lower 
direct  tracheo-bronchoscopy."  In  this  country,  Chevalier  Jackson 
has  perfected  similar  tubes,  in  which,  however,  the  illumination  is 
suppHed  by  a  small  electric  light  at  the  distal  end  of  the  instrument. 

The  bronchoscope  is  employed  both  for  diagnostic  and  ther- 
apeutic purposes,  and  is  of  especial  value  in  locating  and  removing 

Fig.  415 — Killian''.i  bronchoscope. 

foreign  bodies  and  growths  from  the  air  passages,  or  in  making  direct 
applications  to  ulcers  and  other  lesions  in  the  trachea  and  bronchi. 
Marvelous  results  have  been  obtained  by  those  expert  in  the  use  of 
these  instruments,  and  foreign  bodies  have  been  frequently  removed 
from  the  bronchi  of  patients  upon  whom  thoracotomy  would  other- 
wise have  been  required.  The  use  of  the  bronchoscope,  however, 
requires  such  skill  and  practice  as  to  be  only  of  service  in  the  hands 
of  an  accomplished  specialist;  in  unskilled  hands  it  becomes  a  danger- 
ous instrument. 

Tracheo-bronchoscopy  through  a  tracheotomy  wound  is  the 
simpler  of  the  two  methods,  and,  as  larger  tabes  may  be  employed 
than  in  the  upper  operation,  it  is  often  of  value  for  the  removal  of 
foreign  bodies  too  large  to  be  extracted  by  upper  tracheo-bronchos- 
copy. Upper  tracheo-bronchoscopy,  however,  should  be  the  opera- 
tion of  choice  when  possible. 



Instruments. — The  tubes  employed  are  of  rigid,  metal  highly 
polished  internally,  somewhat  similar  to  the  endoscopic  tubes  em- 
ployed in  the  urethra.  They  vary  in  size  according  to  the  age  of 
the  patient  and  the  part  of  the  air  passages  to  be  explored.  Only 
the  smallest  sized  tubes  should  be  used  for  the  bronchi.  Jackson 
employes  for  lower  tracheo-bronchoscopy  a  tube  1/3  inch  (8  mm.)  in 

Fig.  416 — Jackson's  bronchscope. 

diameter  by  8  inches  (20  cm.)  long  for  adults,  and  one  1/5  inch 
(5  mm.)  in  diameter  by  5  1/2  inches  (14  cm.)  long  for  children;  and 
for  upper  tracheo-bronchoscopy  a  tube  7/25  inch  (7  mm.)  in  diame- 
ter by  18  inches  (45  cm.)  long  for  adults,  and  one  1/5  inch  (5 
mm.)  in  diameter  by  8  inches  (20  cm.)  long  for  children. 

Fig.  417. — Jackson's  secretion  aspirator. 

In  Killian's  instruments  (Fig.  415)  illumination  is  supplied  from 
an  electric  head  light.     In  the  Jackson  tubes  (Fig.  416)  the  illu- 
mination is  supplied  by  a  small  electric  light  at  the  distal  end  of 
the  instrument.     These   latter   are   somewhat   easier   to   use   than 



Killian's  instruments.  In  addition,  the  Jackson  instruments  are 
provided  with  a  conduit  to  which  is  attached  a  suction  apparatus 
and  exhaust  pump,  for  the  purpose  of  removing  secretions  that 
may  collect  and  obscure  the  view  (Fig.  417).  For  inserting  these 
instruments,  a  special  split  tube  (Fig.  418),  resembling  that  used 

Fig.  418. — Jackson's  separable  speculum  for  passing  the  bronchoscope.  The 
handle,  ab,  for  use  when  the  patient  is  in  a  sitting  posture;  c,  shows  the  arrangement 
of  the  lamp  at  the  distal  end. 

in  direct  laryngoscopy,  is  supplied  which  is,  removed  in  two  halves 
after  the  bronchoscope  has  entered  the  glottis. 

A  portable  battery  with  rubber-covered  cords,  a  mouth-gag,  a 

Fig.  419. — Accessory  instruments  for  tracheo-bronchoscopy. 

Sajous  applicator,  variously  shaped  forceps,  applicators  for  applying 
cocain  or  drugs  to  '.he  mucous  membrane,  hooks,  etc.,  for  the  removal 
of  foreign  bodies  through  the  instrument,  and  a  tracheotomy  set 



(see  page  426)  are  required.     The  operator  should  also  be  provided 
with  a  number  of  extra  lamps  to  replace  those  that  may  burn  out. 

Asepsis. — Strict  asepsis  in  all  details  is  absolutely  necessary. 
The  tubes  and  accessory  instruments  are  boiled,  the  lighting  appara- 
tus is  sterilized  by  immersion  in  alcohol  or  in  a  i  to  20  carbohc  acid 
solution  followed  by  rinsing  in  alcohol,  and  the  rubber-covered  bat- 
tery cords  are  wiped  off  with  bichlorid  solution.  The  hands  of  the 
operator  and  assistants  should  be  as  thoroughly  cleansed  as  for  any 
operation.  On  account  of  the  danger  of  sepsis  from  the  mouth,  the 
patient's  teeth  should  be  brushed  and  the  mouth  well  cleansed  with 

Fig.  420. — The  position   of   the   patient   and   the   assistant   for   upper   tracheo- 
bronchoscopy.    (After  Jackson.) 

an  antiseptic  wash  before  passing  the  instruments.  A  tube  employed 
in  the  upper  operation  should  not  be  used  for  lower  bronchoscopy 
without  resterilization. 

Preparation  of  the  Patient. — If  general  anesthesia  is  to  be  em- 
ployed, the  patient  should  be  prepared  according  to  the  usual  method 
(page  2).  In  any  case,  the  operation  should  be  performed  on  an 
empty  stomach.  For  lower  tracheo-bronchoscopy,  the  neck,  if 
hairy,  should  be  shaved  and  painted  with  tincture  of  iodin. 

Position  of  the  Patient. — If  done  under  local  anesthesia,  upper 
tracheo-bronchoscopy  may  be  performed  with  the  patient   in  the 



upright  position.  The  patient  sits  on  a  low  stool,  with  the  head  ex- 
tended backward  as  far  as  possible  and  the  tongue  projected  forward. 
An  assistant  holds  the  head  from  behind  and  steadies  the  mouth- 
gag,  w^hile  the  operator  stands  in  front.  When  a  general  anesthetic 
is  employed,  and  in  all  cases  of  lower  bronchoscopy,  the  patient 
should  be  in  the  dorsal  position  on  a  table,  the  front  of  which  is 
slightly  elevated,  wath  the  head  hanging  over  the  edge  of  the  table, 
in  which  position  it  is  supported  by  an  assistant  who  takes  care  of  the 
mouth-gag,  as  shown  in  Fig.  420. 


Fig.  421. — Showing  the  various  steps  in  upper  bronchoscopy.      (After  Jackson.) 

Anesthesia. — In  children,  general  anesthesia  is  necessary.  In 
adults,  preliminary  cocainization  of  the  pharynx  and  larynx  with  a  4 
per  cent,  solution  of  cocain,  followed  by  a  20  per  cent,  solution  of 
cocain,  appHed  to  the  larynx  and  trachea  is  in  most  cases  sufficient, 
unless  the  patient  is  very  excitable,  although  general  anesthesia 
renders  the  operation  easier  in  any  case.  Even  when  general  anes- 
thesia is  used,  cocain  should  be  applied  by  means  of  cotton  applica- 
tors to  the  larynx  and  trachea  before  the  introduction  of  the  tube,  to 
avoid  dangerous  reflexes  from  stimulation  of  the  endings  of  the  su- 
perior laryngeal  nerve. 



Technic. — i.  Upper  Tracheo-bronchoscopy. — With  the  patient  in 
the  proper  position,  and  the  parts  cocainized,  the  mouth  is  widely 
opened  and  the  mouth-gag  is  inserted  and  given  to  the  assistant  to 
maintain  in  position.  The  larynx  and  vocal  cords  are  exposed  by 
introducing  a  split  tube  spatula,  as  for  direct  laryngoscopy  (page 
398).  Thebronchoscope,  well  lubricated  with  sterile  vaseHn,  andwith 
the  illumination  properly  turned  on,  is  passed  through  the  split  tube 
as  far  as  the  epiglottis  under  the  guidance  of  the  operator's  eye. 
The  operator  notes  the  vocal  cords  and  instructs  the  patient  to  breathe 
deeply,  and,  while  the  cords  are  open  during  inspiration,  the  instru- 
ment is  gently  passed  through  the  glottis  until  it  enters  the  trachea. 
The  split  tube  is  then  separated  and  removed.  As  the  bronchoscope 
is  advanced,  the  mucous  membrane  in  front  should  be  anesthetized 
by  means  of  a  20  per  cent,  solution  of  cocain  applied  with  cotton 
swabs  on  a  long  applicator.     The  instrument  is  thus  slowly  passed 

Fig.  422. — Lower  bronchoscopy.     (Modified  from  Ballanger.) 

to  the  bifurcation  of  the  trachea,  and  the  parts  are  examined  in  detail 
as  the  tube  advances. 

To  enter  the  right  bronchus,  the  instrument  should  be  turned 
toward  the  left  angle  of  the  patient's  mouth,  and  toward  the  right 
side  if  the  left  bronchus  is  to  be  entered.  By  very  careful  and  gentle 
manipulations  with  the  tube,  and  by  using  the  smallest  sizes,  the 
secondary  and  even  the  third  division  of  the  bronchi  may  be  inspected 
by  one  especially  skilled  in  this  work. 

During  the  examination,  secretions  or  blood  may  be  removed  by 
means  of  cotton  wrapped  on  long  applicators  or  by  the  special  aspirat- 
ing apparatus  supplied  with. the  instrument,  the  manipulation  of 
which  is  entrusted  to  an  assistant.  In  this  way  the  entire  mucous 
membrane  lining  the  trachea  may  be  examined,  foreign  bodies  located 
and  removed,  and  lesions  treated  by  direct  application. 



2.  Lower  Tracheo-bronchoscopy. — Low  tracheotomy  is  first  per- 
formed as  described  on  page  432.  After  all  the  bleeding  has  been 
controlled,  a  Trousseau  dilator  is  inserted  and  the  tracheal  wound  is 
held  open.  The  mucous  membrane  of  the  trachea  is  then  cocainized 
with  a  20  per  cent,  solution  of  cocain.  A  short  bronchoscope,  with 
the  illumination  turned  on,  is  then  introduced,  and  the  instrument 
is  advanced  under  the  guidance  of  the  operator's  eye,  which  is  applied 
at  the  end  of  the  instrument.  As  soon  as  the  bifurcation  of  the  tra- 
chea is  reached,  the  tube  may  be  directed  into  either  bronchus  by 

Fig.  423. — Instruments  for  probing  the  larynx.      I,  Laryngeal  probe;  2,  laryngeal 
mirror;  3,  alcohol  lamp;  4,  head  mirror. 

gentle  manipulation.  The  patient's  head  is  turned  sideways,  and,  if 
the  right  bronchus  is  to  be  entered,  the  tube  is  inserted  on  the  left 
side  of  the  head;  if  the  left  bronchus  is  to  be  examined,  the  tube  is 
inserted  at  the  right  side  of  the  head.  The  bronchi  should  be  anesthet- 
ized, as  before,  in  advance  of  the  instrument  with  cocain  applied  upon 
long  applicators  through  the  instrument,  and  the  examination  pro- 
ceeded with  as  above. 

The  after-treatment  of  the  patient  consists  in  inserting  a  tracheot- 
omy tube  which  is  worn  for  several  days.     After  the  removal  of  this 


tube,  the  wound  should  be  carefully  protected  by  a  gauze  dressing  and 
cleansed  daily,  being  allowed  to  heal  from  the  bottom  up. 


Palpation  by  the  probe  is  of  value  in  determining  the  consistency 
and  extent  of  new  growths,  the  depth  and  size  of  ulcerations,  the 
presence  of  necrosed  cartilage,  and  the  sensibility  of  the  mucous 

Instruments. — A  laryngeal  mirror,  an  alcohol  lamp,  a  head  light, 
and  a  laryngeal  probe  are  necessary  (Fig.  423). 

Asepsis.  -The  probe  should  be  boiled  and  the  laryngeal  mirror 
sterilized  by  immersion  in  a  i  to  20  solution  of  carbolic  acid,  then 
rinsed  off  in  sterile  water  and  dried  before  use. 

Position  of  Patient. — The  patient  is  in  the  same  position  as  for 
ordinary  laryngoscopy. 

Anesthesia. — The  larynx  should  be  cocainized  by  spraying  or  by 
the  application  of  a  lo  per  cent,  solution  of  cocain. 

Technic. — The  tongue  is  protruded  and  held  by  the  patient  with  a 
cloth,  and  the  laryngeal  mirror  is  warmed  and  inserted  in  such  a 
position  that  a  good  view  of  the  larynx  is  obtained.  The  probe  is 
held  in  the  operator's  right  hand  and  is  introduced  into  the  patient's 
mouth  turned  on  its  side,  with  the  laryngeal  portion  horizontal  and 
the  handle  in  the  angle  of  the  mouth  until  it  almost  reaches  the  pos- 
terior pharyngeal  wall  (see  Fig.  424).  It  is  then  brought  into  the 
natural  position,  with  the  laryngeal  portion  vertical  and  the  handle  in 
the  mid-line,  the  point  of  the  instrument  lying  in  the  pharynx  behind 
the  epiglottis.  By  raising  the  handle  of  the  instrument,  the  point  is 
then  brought  forward  over  the  arytenoids.  By  directing  the  point  of 
the  probe,  guided  by  the  image  in  the  mirror,  the  diseased  areas  are 
then  explored  (see  Fig.  425).  In  performing  this  manipulation,  it 
must  be  remembered  that  the  image  in  the  mirror  is  reversed,  so  that 
movements  of  the  instrument  will  likewise  appear  reversed,  and  that 
the  distance  between  the  arytenoids  and  the  vocal  cords  is  much 
greater  than  appears  in  the  image. 

In  introducing  any  laryngeal  instrument,  such  as  applicators, 
brushes,  forceps,  etc.,  of  the  same  shape  as  the  laryngeal  probe,  that 
is,  with  long  handles  and  a  laryngeal  piece  at  right  angles,  or  nearly  so, 
with  the  handle,  the  same  technic  should  be  employed;  otherwise,  if 
the  instrument  is  introduced  into  the  mouth  with  the  laryngeal  end 
held  vertically,  it  is  usually  impossible  to  insert  the  laryngeal  portion 
between  the  palate  and  base  of  the  tongue. 



Skiagraphy  is  employed  as  an  adjunct  to  other  diagnostic  meas 
ures  for  locating  metal  and  other  foreign  bodies  which  are  impene- 
trable to  the  rays,  and  also  for  localizing  certain  growths  of  greater 
density  than  the  surrounding  tissues. 

Therapeutic  Measures 

The  laryngeal  spray  is  employed  for  the  purpose  of  cleansing  and 
for  medication.  Cleansing  of  the  larynx  is  frequently  required  for 
the  removal  of  purulent  secretions  the  result  of  syphihticor  tubercular 
ulcerations,  and  to  soften  and  wash  away  the  crusts  which  are  often 
an  accompaniment  of  fetid  laryngitis.  Whenever  possible,  spraying 
of  the  larynx  should  be  done  by  the  surgeon  himself,  as  it  can  thus 
be  performed  by  the  aid  of  direct  vision  in  a  thorough  manner.  If 
this  is  not  possible,  the  patient  must  be  very  carefully  instructed  in 
the  use  of  the  instrument. 

Medication  of  the  larynx  may  be  required  in  the  treatment  of 
acute  and  chronic  inflammations,  ulcerations,  etc.,  and  according  to 
the  indications  of  the  individual  case,  remedies  with  an  antiseptic, 
astringent,  sedative,  stimulating,  or  caustic  action  are  employed. 
These  may  be  used  in  the  form  of  watery  or  oily  solutions.  The 
great  sensitiveness  of  the  laryngeal  mucous  membrane  should  be 
kept  in  mind  in  making  any  topical  application,  and  the  use  of  very 
irritating  drugs  should  be  avoided. 

Instruments. — It  is  important  to  select  a  spray  that  will  not  expel 
the  solution  in  such  a  powerful  stream  as  to  produce  irritation  and 
possibly  add  to  the  local  inflammation.  The  Davidson,  the  Whitall 
Tatum  (see  Fig.  336),  and  the  De  Vilbiss  atomizers  (see  Fig.  337)  are 
simple  and  very  efficient  instruments.  They  should  be  provided  with 
a  laryngeal  nozzle,  which  turns  downward.  The  air  current  may  be 
supplied  by  a  rubber  compression  bulb  or  by  means  of  a  compressed- 
air  apparatus  (see  Fig.  338). 

A  head  mirror,  a  laryngeal  mirror,  and  proper  illumination  will 
also  be  required  when  the  spraying  is  to  be  done  by  the  operator  under 
direct  vision. 

Solutions. — For  cleansing  purposes,  the  alkaline  solutions  recom- 
mended on  page  327  for  use  in  the  nose  may  be  employed.     For 


topical  applications  to  the  larynx,  the  formulae  of  antiseptic,  astrin- 
gent, sedative,  and  stimulating  solutions  given  on  page  331,  for  use 
in  the  nose,  may  be  employed  according  to  the  indications. 

Temperature. — The  solutions  should  always  be  used  warm,  at 
a  temperature  of  about  100°  F.  (38°  C), 

Anesthesia. — When  the  parts  are  very  sensitive,  preliminary 
spraying  with  a  10  per  cent,  solution  of  cocain  may  be  required. 

Technic. — -The  patient  is  directed  to  open  his  mouth  widely  and 
to  protrude  his  tongue,  which  he  may  hold  forward  with  the  fingers  of 
his  right  hand  if  desired.  The  operator  then  warms  and  introduces 
a  laryngeal  mirror,  holding  it  so  as  to  obtain  a  good  view  of  the  parts. 
Then,  with  his  right  hand,  he  introduces  the  spray  nozzle  into  the 
mouth,  and  with  the  aid  of  the  mirror  passes  it  behind  the  epiglottis 
and  depresses  the  tip  so  that  it  points  toward  the  diseased  area. 
When  the  nozzle  is  in  proper  position,  the  mirror  is  removed  and  the 
bulb  of  the  spray  is  sharply  compressed,  the  patient  being  instructed 
to  phonate  while  this  is  being  done.  The  spray  is  then  immediately 
removed,  as  the  patient  will  cough  and  want  to  expectorate.  When 
performed  for  cleansing  purposes,  the  spraying  should  be  repeated 
several  times  until  the  larynx  is  well  washed  out.  Each  time  the 
patient  coughs,  mucus,  purulent  secretion,  and  crusts,  which  have 
been  softened  and  separated  by  the  spray,  will  be  expelled. 

When  the  spraying  is  carried  out  by  the  patient,  the  mouth  is 
widely  opened  and  the  tongue  protruded  as  before.  The  spray  noz- 
zle, held  in  the  patient's  right  hand,  is  then  introduced  well  back  of  the 
tongue,  with  the  tip  directed  downward  and  forward  over  the 
larynx,  and,  while  the  patient  phonates,  the  bulb  is  sharply  com- 
pressed. In  employing  oily  preparations,  the  patient  should  take  an 
inspiration  at  the  moment  of  compressing  the  bulb,  so  as  to  aid  in 
drawing  the  solution  into  the  larynx.  Until  the  patient  becomes 
skilled  in  the  introduction  of  the  spray,  it  is  well  for  him  to  perform 
the  operation  standing  in  front  of  a  mirror. 


This  method  is  indicated  when  it  is  desired  to  apply  remedies  to 
some  particular  spot,  especially  when  strong  stimulants  or  caustics 
are  used.  Liquids  may  be  appHed  by  means  of  swabs  or  brushes. 
SoHd  caustics  should  be  fused  on  a  probe.  The  application  should 
be  made  with  the  aid  of  a  laryngeal  mirror,  and  great  care  must  be 
taken  to  avoid  bruising  the  tissues  or  causing  trauma. 



Instruments. — For    the    application    of    liquids,    a    camel's-hair 
brush,  mounted  on  a  wire  which  is  bent  at  right  angles  about  21/2 

Fig.  424  — Method  of  inserting  the  laryngeal  applicator. 

Fig.  425. — Shows  the  method  of  making  direct  applications  to  the  larynx  by  the  aid 

of  the  laryngeal  mirror. 

to  3  inches  (6  to  7  cm.)  from  the  end  and  inserted  into  a  handle,  a 
Sajous  appUcator  (see  Fig.  413),  or  an  ordinary  laryngeal  applicator 
wrapped  with  cotton  may  be  employed.     In  making  use  of  the  latter, 


care  sliould  be  taken  that  the  cotton  is  wrapped  tightly  about  the  end 
of  the  instrument,  so  that  there  is  no  danger  of  its  falHng  off  and  sHp- 
ping  into  the  larynx. 

Solid  caustics,  as  silver  nitrate  and  chromic  acid,  may  be  applied 
fused  on  the  end  of  a  laryngeal  probe,  as  described  on  page  334. 

Anesthesia. — The  parts  should  be  anesthetized  by  means  of  a  10 
per  cent,  solution  of  cocain  applied  by  means  of  a  spray  or  on  a  cotton 

Technic. — -The  laryngeal  mirror  is  warmed  and  introduced  by 
the  operator's  left  hand,  so  as  to  obtain  a  clear  view  of  the  parts  to  be 
medicated.  If  secretion  or  mucus  be  present,  the  parts  should  be 
first  cleansed  by  spraying.  The  applicator  is  then  dipped  in  the 
solution  to  be  applied,  and  any  excess  of  fluid  is  removed  to  prevent  it 
from  running  into  the  trachea.  This  precaution  is  especially  neces- 
sary when  using  strong  solutions  or  caustics.  The  instrument,  held 
in  the  operator's  right  hand,  is  then  introduced  into  the  mouth,  with 
the  curved  surface  held  first  horizontally  (Fig.  424),  and  then,  as  soon 
as  the  tip  of  the  instrument  reaches  the  pharynx,  turned  to  a  vertical 
position.  The  applicator  is  then  guided  to  the  desired  spot  by  the 
aid  of  the  laryngeal  mirror  (Fig.  425).  The  application  should  be 
made  with  great  gentleness  and  care  and  the  instrument  quickly 

The  appHcation  of  acids  is  carried  out  in  the  same  manner,  any 
excess  of  acid  being  immediately  neutralized  by  the  application  of  a 
solution  of  bicarbonate  of  soda,  gr.  xxx  (2  gm.)  to  the  ounce  (30  c.c). 
A  dusting  powder  may  finally  be  applied  to  the  cauterized  area. 


Powders  may  be  applied  to  the  larynx  by  means  of  a  special 
insufflator.  They  are  of  use  chiefly  in  cases  of  ulceration,  where  a 
sedative  or  antiseptic  action  is  desired.  A  combination  of  nosophen, 
aristol,  europhen,  iodoform,  etc.,  with  finely  powdered  starch,  stearate 
of  zinc,  or  powdered  acacia  as  a  base,  are  usually  employed  in  the  pro- 
portion of  one  part  of  the  active  principle  to  two  parts  of  the  base. 
Small  amounts  of  morphin  or  cocain  may  also  be  combined  with  the 
base  and  applied,  when  indicated,  for  the  relief  of  pain. 

Instruments. — A  laryngeal  powder  blower,  a  head  light,  a  laryn- 
geal mirror,  an  alcohol  lamp,  and  suitable  illumination  are  necessary. 
The  insufflator  shown  in  Fig.  426  is  very  convenient,  as  with  it  the 
amount  of  powder  may  be  accurately  measured,  and  the  instrument 
may  be  manipulated  with  one  hand. 



Technic. — The  laryngeal  mirror  is  warmed  and  properly  inserted 
into  the  pharynx,  so  that  a  good  view  of  the  parts  to  be  medicated  is 
obtained.  The  insufflator,  filled  with  the  desired  amount  of  powder, 
is  inserted  in  the  mouth  and  carried  back  to  the  larynx  under  the 
guidance  of  the  image  in  the  mirror.  When  in  proper  position,  a 
sudden  compression  on  the  bulb  forces  out  the  powder  and  deposits  it 
on  the  diseased  surface.  If  it  is  desired  to  carry  the  powder  deep  into 
the  larynx,  the  patient  should  be  requested  to  phonate  at  the  moment 
of  compressing  the  bulb. . 

Fig.  426. 

-Instruments  for  applying  powders  to  the  larynx,     i,  Powder  blower;  2, 
laryngeal  mirror;  3,  alcohol  lamp;  4,  head  mirror. 


By  means  of  steam  inhalations  the  active  principle  of  certain  drugs 
that  are  readily  volatilized  by  heat  may  be  brought  into  contact  with 
the  mucous  membrane  of  the  respiratory  tract  and  carried  beyond 
the  larynx  to  the  trachea  and  bronchi.  The  effect  of  the  steam  itself 
is  also  valuable,  for  it  acts  as  an  anodyne  upon  inflamed  mucous  mem- 
branes by  supplying  moisture  and  so  reHeving  the  heat  and  dryness  of 
congestion.  In  the  latter  stages  of  an  inflammation  the  steam,  fur- 
thermore, dilutes  and  assists  in  removing  secretions.  Steam  inhala- 
tions are  thus  of  great  value  in  congestion  and  edema  of  the  larynx, 



croup,  membranous  laryngitis,  and  bronchitis.  They  are  especially 
serviceable  in  softening  the  thick  tenacious  secretion  of  chronic 

Fig.  427. — Croup  kettle. 

Fig.  428. — Steam  atomizer. 
Fig.  429. — Steam  inhaler  improvised  from  a  coffee-pot>. 

The  Inhaler. — When  it  is  simply  intended  to  convey  the  vapor  to 
the  vicinity  of  the  patient,  a  croup  kettle  with  a  long  spout,  such  as 



shown  in  Fig.  427,  is  most  convenient.  For  direct  inhalation,  more 
or  less  elaborate  forms  of  apparatus  are  manufactured  (Fig.  428),  but 
a  coffee-pot  with  a  funnel  of  heavy  paper  placed  in  the  top  makes  a 
simple  and  efficient  inhaler  (Fig.  429). 

Formulary. — Sedative,  stimulating,  or  antiseptic  drugs  are  the 
ones  usually  employed  for  inhalation.  These  include  tincture  of 
benzoin  compound  in  the  strength  of  i  5  (4  c.c.)  to  the  pint  (500  c.c.) ; 
creosote,  5  to  10  TU  (0.3  to  0.6  c.c.)  to  the  pint  (500  c.c);  ol. 
cubebae,  sT([  (0.3  c.c.)  to  the  pint  (500  c.c);  spirits  camphori.  sTIft 

Fig.  430. — Crib  arranged  for  steam  inhalations.      (After  Kerley., 

(0.3  c.c.)  to  the  pint  (500  c.c);  ol.  pinus  sylvestris,  5  Tn,(  0.3  c.c.) 
to  the  pint  (500  c.c),  etc. 

Temperature. — When  directly  inhaled,  the  vapor  should  not  be  of 
a  higher  temperature  than  150°  F.  (65°  C).  If  used  at  too  high  a 
temperature,  irritation  of  the  mucous  membrane  may  be  produced 
and  there  is  danger  of  the  steam  scalding  the  face. 

Technic. — Into  an  inhaler  a  pint  (500  c.c.)  of  nearly  boiling  water 
is  placed  and  the  proper  quantity  of  the  drug  is  added.  The  patient 
then  places  his  nose  over  the  cone  and  inhales  the  escaping  vapor, 
taking  about  six  to  eight  breaths  a  minute.  The  inhalation  should 
not  be  continued  for  more  than  five  or  ten  minutes  at  a  time.  It  may 
be  employed  three  or  four  times  daily.  The  treatment  should  be 
carried  out  in  a  warm  room,  i.e.,  at  a  temperature  of  about  68° 
F.,  (20°  C.)  and  care  should  be  taken  to  protect  the  patient  from 
draughts.     As  the  steam  relaxes  the  mucous  membrane  and  renders 


the  patient  susceptible  to  cold,  he  should  not  be  allowed  out  of  doors 
for  several  hours  afterward. 

In  using  the  croup  kettle,  the  steam  may  be  delivered  into  the 
room  or  directly  over  the  patient.  When  the  latter  method  is  used, 
it  is  well  to  cover  the  bed  of  the  patient  with  a  sheet  arranged  in  the 
form  of  a  tent  and  raised  sufficiently  high  to  permit  a  free  circulation 
of  air,  the  nozzle  of  the  croup  kettle  being  inserted  under  one  side  of 
the  tent  and  the  water  kept  boiling  (Fig.  430). 


These  are  useful  in  diseases  of  the  upper  respiratory  tract  for  those 
who  cannot  tolerate  the  steam  inhalations.  The  method  has  an 
advantage  over  steam  inhalations  in  that  the  patient  does  not  have  to 
remain  in  the  house  afterward. 

Fig.  431. — Inhalation  mask. 

The  Inhaler. — A  special  mask  made  of  woven  metal,  which  accu- 
rately fits  the  mouth  and  which  is  provided  with  a  sponge  upon  which 
the  medication  is  dropped,  is  employed  (Fig.  431). 

Formulary. — Any  of  the  very  volatile  oils,  such  as  thymol,  men- 
thol, eucalyptol,  etc.,  may  be  employed. 

Technic. — Twenty  or  thirty  drops  (1.25  to  2  c.c.)  of  the  oil  are 
placed  upon  the  sponge  of  the  mask  and  the  latter  is  placed  over  the 
patient's  face  and  is  secured  by  strings  fastened  back  of  the  head  and 
neck.  The  patient  inhales  through  the  mask  by  means  of  the  mouth, 
and  exhales  through  the  nose.  The  mask  may  be  worn  for  about  half 
an  hour  two  or  three  times  a  day. 


Intubation  of  the  larynx,  an  operation  devised  by  O'Dwyer, 
consists  in  the  introduction  of  a  tube  into  the  larynx  for  the  purpose  of 
securing  free  respiration  in  the  presence  of  obstruction  in  the  larynx 



or  upper  portion  of  the  trachea.  It  is  an  operation  which  gives 
prompt  rehef  without  the  necessity  of  cutting  and  without  producing 
any  loss  of  blood  or  shock.  It  is  less  terrifying  to  the  patient 
than  the  tracheotomy  and  the  after-care  is  not  so  troublesome. 
Anesthesia  is  not  required  nor  is  any  previous  preparation  of  the 
patient  required.  Special  instruments,  however,  are  necessary,  and 
the  feeding  of  the  patieiit  is  often  troublesome  and,  while  not  a  diffi- 
cult operation  in  itself,  it  requires  special  training  for  its  skilful  per- 
formance which  is  best  learned  by  practice  upon  the  cadaver. 

Fig.  432. — O'Dwyer  intubation  instruments,  i,  Tube  with  obturator  in  place* 
2,  tube  and  obturator  separated;  3,  gauge;  4,  mouth  gag;  5,  introducer;  6,  silk 
thread;  7  extractor. 

Indications. — The  operation  was  originally  devised  for  the  relief 
of  obstruction  to  respiration  in  cases  of  laryngeal  diphtheria  and  has 
now  almost  entirely  supplanted  tracheotomy  in  such  cases.  The 
immediate  indications  are  dyspnea  accompanied  by  cyanosis,  depres- 
sion of  the  suprasternal  and  supraclavicular  spaces  on  inspiration, 
and  sinking  in  of  the  lower  portion  of  the  chest.  Intubation  is  also 
employed  in  laryngeal  stenosis  from  other  causes  for  the  purpose  of 
producing  gradual  dilatation  of  the  parts,  progressively  larger 
tubes  being  introduced  and  worn  for  a  few  days  at  a  time. 

Instruments. — The  instruments  required  are  an  O'Dwyer  intuba- 
tion set  including  seven  metal  or  hard-rubber  tubes,  an  introducer, 


an  extractor,  a  mouth  gag,  and  a  gauge  indicating  the  size  of  the  tubes 
according  to  the  age  of  the  patient  (Fig.  43  2) .  Although  these  instru- 
ments have  been  modified  and  attempts  have  been  made  to 
improve  upon  them,  those  originally  designed  by  O'Dwyer  give  the 
best  results. 

The  intubation  tube  has  an  expanded  head  prolonged  backward 
in  the  form  of  a  flange  to  prevent  it  from  slipping  through  the  vocal 
cords  and  a  fusiform  bulb  in  the  middle  to  aid  in  keeping  the  tube  in 
position.  In  the  anterior  portion  of  the  head  a  perforation  is  pro- 
vided for  the  attachment  of  a  piece  of  silk  thread.  The  lower  end  of 
the  tube  is  rounded  off  and  oval.  Each  tube  is  provided  with  an 
obturator  which  can  be  screwed  on  to  the  introducer.  The  free 
extremity  of  the  obturator  ends  in  a  protuberance  which  projects 
beyond  the  tube  and  prolongs  the  latter  into  a  rounded  extremity  to 
aid  in  its  introduction. 

The  introducer,  or  intubator,  consists  of  a  handle  in  which  is  set  a 
rod,  to  the  extremity  of  which  the  obturator  may  be  screwed.  A 
sliding  joined  tube  fits  over  this,  which  can  be  pushed  forward  by  a 
small  knob  set  on  the  handle  of  the  instrument,  thereby  detaching 
the  intubation  tube  from  the  obturator  when  the  former  is  in  proper 
position  in  the  larynx. 

The  extractor,  or  extubator,  is  an  instrument  supplied  with  jaws 
which  fit  into  the  lumen  of  the  tube,  and  when  opened  by  pressure 
upon  a  lever  engage  the  tube  with  sufficient  force  to  permit  its  removal 
from  the  larynx. 

Asepsis. — The  instruments  should  be  sterilized  before  use. 

Position  of  the  Patient. — The  child,  with  its  arms  at  its  sides,  is 
wrapped  from  chin  to  foot  in  a  sheet  or  blanket  and  is  supported  upon 
the  lap  of  a  nurse  in  a  sitting  posture  facing  the  operator  with  its  feet 
held  between  the  nurse's  knees  and  its  head  resting  on  her  right 
shoulder.  An  assistant  should  stand  behind  and  grasp  the  child's 
head  firmly,  lifting  upward  as  though  holding  the  child  by  the  head, 
thus  extending  the  child's  head  as  far  as  possible  (Fig.  433).  Some 
operators,  however,  prefer  to  intubate  with  the  patient  in  a  horizontal 
position  and  with  a  small  sand-bag  placed  under  the  back  of  the  neck. 

Technic. — A  tube  of  a  size  corresponding  to  the  age  of  the  patient 
is  selected  and  is  properly  threaded  mth  a  piece  of  silk  2  or  3  feet 
(60  to  90  cm.)  long.  Then,  with  the  obturator  in  place,  the  tube  is 
screwed  on  the  introducer  in  such  a  manner  that  its  projecting 
flange  lies  behind  and  faces  away  from  the  operator.  The  mouth  gag 
is  next  inserted  between  the  patient's  jaws  on  the  left  side  and  is  held 



in  place  by  the  assistant  who  supports  the  child's  head.  The  opera- 
tor, with  his  eyes,  nose,  and  mouth  protected  against  possible  infec- 
tion in  diphtheria  cases,  faces  the  patient  and  inserts  his  left  index- 

FlG.  433. — Position  of  child  for  intuabation  and  method  of  holding. 

Fig.  434. — Intubation.     First  step,  showing  the  method  of  drawing  the  epiglottis 


finger  into  the  mouth,  hooking  up  the  epiglottis  (Fig.  434).  In  doing 
this  care  should  be  taken  to  keep  the  finger  to  the  left  side  and  out  of 
the  way  as  much  as  possible.  The  operator  then  takes  the  introducer 
with  the  tube  attached  in  his  right  hand,  holding  it  as  follows:  The 
thumb  pressed  against  the  button  on  the  upper  side  of  the  handle,  the 



index-iinger  around  the  hook  on  the  under  surface  of  the  instrument, 
and  the  loop  of  silk  wound  over  his  little  finger,  as  shown  in  Fig. 
435.     He  then  slowly  introduces  the  tube  into  the  mouth  in  the  me- 

FiG.   435. — Showing  the  intubation  tube  on  the  introducer  and  the  method   of 

holding  the  latter. 

dian  Kne,  hugging  the  center  of  the  tongue  and  keeping  the  handle  of 
the  instrument  at  first  well  down  on  the  chest  of  the  patient  (Fig. 
436).     When  the  end  of  the  tube  reaches  the  epiglottis  (Fig.  437),  the 

Fig.  436. — Intubation.     Second    step,   introducing   the   tube   into   the   patient's 


handle  is  sharply  elevated,  so  that  the  tube  is  brought  into  a  vertical 
position  (Fig.  438).  If  the  handle  of  the  instrument  is  not  sufficiently 
elevated,  the  tube  will  point  toward  the  entrance  of  the  esophagus 
which  it  will  be  apt  to  enter  during  the  next  maneuver  (Fig.  439).  At 



the  same  time  the  finger  of  the  operator  is  moved  to  the  posterior 
portion  of  the  larynx,  resting  on  the  arytenoid  cartilages  to  prevent 
the  tube  from  entering  the  esophagus.  The  tube  is  then  gently 
pushed  through  the  chink  of  the  glottis  and  on  into  the  larynx,  guided 
by  the  operator's  finger.     No  force  whatever  should  be  used. 

Fig.  437. — Third  step  in  intubation.       FiG.  438. — Fourth  step  in  intubation. 

As  soon  as  the  tube  is  in  proper  position,  the  operator's  forefinger 
is  placed  on  its  head  holding  it  in  place  while  the  button  on  the  handle 
of  the  instrument  is  pushed  forward,  thus  disengaging  the  obturator 
from    the    tube    (Fig.    440).     The    intubator    with    the    obturator 

Fig.  439. — Showing  a  faulty  position  Fig.  440. — Fifth  step  in  intubation 

of  the  tube,  due  to  the  handle  of  the  in-  withdrawing     the    introducer     while 

troducer  not  being  raised  sufficient]}-  index-finger  holds  the  tube  in  place, 

attached  is  then  removed,  and  the  tube  is  pushed  well  into  the  larynx 
by  the  finger  (Fig.  441).  Not  more  than  five  to  ten  seconds  should  be 
consumed  in  introducing  the  tube,  for  while  this  is  being  done  breath- 
ing is  interfered  with;  if  the  tube  cannot  be  promptly  inserted,  the 
operation  should  be  suspended  and  a  second  attempt  made  after 
allowing  the  child  time  to  recover  its  breath. 



If  the  tube  is  properly  placed,  there  may  be  at  first  some  cough, 
but  the  breathing  rapidly  becomes  easier,  and  the  cyanosis  is  quickly 
relieved.  After  the  tube  is  in  position,  it  is  well  to  wait  for  ten  or 
fifteen  minutes,  to  make  sure  that  there  is  no  obstruction  to  free 

Fig.  441. — Sixth  step  in  intubation, 
showing  the  index-finger  pushing  the 
tube  well  into  the  larynx. 

Fig.  442. — Showing  the  intubation 
tube  in  place. 

respiration.  When  certain  that  the  tube  is  properly  placed  in  the 
larynx,  the  mouth  gag  is  reinserted,  and  one  strand  of  silk  is  cut  near 
the  angle  of  the  mouth,  and  the  string  is  withdrawn,  the  forefinger 
being  placed  on  the  tube  to  maintain  it  in  position  (Fig.  443).     Some 

Fig.  443. — Final  step  in  intubation,  removing  the  string  from  the  tube. 

operators  prefer  to  leave  the  string  attached  for  the  removal  of  the 
tube  in  case  of  sudden  emergency.  If  this  is  done,  the  string  should 
be  brought  out  the  corner  of  the  mouth,  hooked  over  the  ear,  and 
secured  by  adhesive  plaster.     This  method  has  the  disadvantage, 



however,  of  furnishing  a  chance  for  the  child  to  remove  the  tube  if  it 
gets  hold  of  the  string.  ? 

Should  t  he  tube  be  placed  in  the  esophagus  by  mistake,  there  will 
be  no  relief  to  the  dyspnea  and  the  cyanosis,  there  will  be  an  absence 
of  cough,  and  the  string  of  silk  will  be  seen  to  gradually  shorten  as  the 
tube  passes  down  the  esophagus.  In  such  a  case,  the  tube  should  be 
removed  by  pulling  on  the  string,  and,  after  waiting  a  sufficient  time 

Fig.  444. — Method  of  feeding  an  intubation  patient  with  the  head  lowered. 

or  the  patient  to  recover  from  the  excitement  attending  the  opera- 
tion, it  should  be  reintroduced. 

In  some  instances,  the  tube  may  become  occluded  by  pushing  the 
false  membrane  ahead  of  it.  If  this  occurs,  the  tube  should  be 
removed  at  once,  and,  if  the  obstructing  membrane  is  not  expelled 
from  the  larynx  and  cannot  be  extracted  and  suffocation  seems 
imminent,  tracheotomy  should  be  performed.  Care  should  be  taken 
not  to  select  too  small  a  tube,  for  it  may  be  expelled  by  coughing  or 
may  escape  into  the  trachea. 

Feeding  Intubated  Patients. — The  tube  renders  swallowing  diffi- 
cult, and  the  patients  are  only  able  to  take  liquid,  or,  at  most,  semi- 
solid food.     As  a  rule,  by  having  the  patient  lie  with  the  head  lowered, 



fluids  will  pass  along  th.e  roof  of  the  mouth  to  the  posterior  pharyngeal 
wall,  and  wall  enter  the  esophagus,  and,  if  given  slowly,  sufficient  food 
may  be  administered  in  this  way  (Fig.  444) ;  or  food  may  be  admin- 
istered by  having  the  patient  suck  up  the  food  through  a  tube  while 
lying  face  downward  upon  the  lap  of  a  nurse.  In  some  cases,  where 
the  patient  refuses  foods,  liquids  may  be  administered  by  means  of  the 
stomach-tube  passed  through  the  mouth  or  by  means  of  a  soft-rubber 
catheter  passed  into  the  stomach  through  the  nose  (page  502),  though 
by  the  continued  use  of  the  latter  method  there  is  danger  of  producing 
infection  of  the  middle  ear.  Rectal  feeding  may  be  combined  with 
the  above  if  indicated. 

When  to  Remove  the  Tube. — The  tube  should  always  be  removed 
as  soon  as  possible,  as  its  prolonged  use  may  produce  ulceration  of  the 
larynx.  In  cases  of  diphtheria,  where  antitoxin  has  been  adminis- 
tered, the  tube  may  be  removed  in  three  to  seven  days,  depending  to 
some  extent  upon  the  age  of  the  patient,  being  left  in  for  longer  inter- 
vals in  very  young  children.  If  the  tube  becomes  occluded  at  any 
time,  it  must  be  removed  -^dthout  delay,  cleaned,  and  then  reintro- 
duced. When  the  tube  is  to  be  permanently  removed,  the  physician, 
after  extracting  it,  should  wait  sufficiently  long  to  see  that  respiration 
does  not  become  impeded  and  necessitate  its  reintroduction. 

Technic  of  Extubation.— The  patient  is  placed  and  held  in  the 
same  position  as  for  introduction  of  the  tube.  The  mouth  gag  is 
inserted,  and  the  operator  passes  his  left  index-finger  into  the  mouth 
and  over  the  epiglottis  until  it  rests  on  the  head  of  the  tube.  The 
extubator,  held  in  the  operator's  right  hand,  is  then  introduced  with 


its  jaws  closed,  by  the  same  maneuvers  employed  in  introducing  the 
intubator,  until  its  tip  is  felt  by  the  finger  on  the  tube.  It  is  then 
carefully  guided  into  the  lumen  of  the  tube.  By  pressing  the  lever  on 
top  of  the  handle,  the  jaws  of  the  instrument  are  separated  and  obtain 
a  secure  hold  on  the  tube,  so  that  it  may  be  easily  withdrawn  (Fig. 
417).  To  accomplish  this,  the  tube  must  be  lifted  at  first  vertically 
upward.  The  handle  of  the  instrument  is  then  depressed,  and  the 
tube  is  brought  out  by  a  reversal  of  the  movements  of  intubation. 

In  an  emergency,  when  the  tube  becomes  obstructed,  it  may  be 
possible  to  remove  it  by  enucleation,  especially  if  the  tube  be  short. 
This  consists  in  placing  the  thumb  of  the  right  hand  on  the  larynx 
beneath  the  end  of  the  tube  while  the  patient's  head  is  extended,  and 
with  a  quick  motion  of  the  head  forward,  at  the  same  time  exerting 
upward  pressure  on  the  larynx,  the  tube  is  expelled  into  the  mouth. 


The  term  tracheotomy  is  generally  used  to  designate  the  operation 
of  opening  into  the  air-passages  at  some  point  between  the  sternum 
and  thyroid  cartilage.  To  be  exact,  however,  the  term  should  be 
limited  to  operations  below  the  cricoid  cartilage,  while  above  that 
point,  that  is,  in  the  cricothyroid  space,  the  operation  is  called  lar^-n- 
gotomy.  Tracheotomy  is  subdivided  into  the  high  operation  when 
the  opening  is  made  above  the  isthmus  of  the  thyroid  gland,  and  into 
low  tracheotomy  when  the  operation  is  performed  below  this  point. 

Indications. — Tracheotomy  is  indicated  for  the  relief  of  obstruc- 
tive dyspnea,  which  may  be  the  result  of  any  one  of  the  following 
conditions:  The  formation  of  pseudomembrane;  the  presence  of 
foreign  bodies;  the  presence  of  growths  within  the  larynx  or  trachea 
or  external  to  these  structures;  edema  of  the  larynx;  spasm  of  the 
larynx;  rapid  swelling  of  the  tonsils  and  pharynx;  injuries  to 
the  larynx  and  trachea,  such  as  contusions,  fractures,  burns,  cicatri- 
cial stenosis,  etc.  For  the  relief  of  obstruction  from  diphtheritic 
membranes,  however,  intubation  should,  as  a  rule,  be  the  operation 
of  choice,  tracheotomy  being  reserved  for  those  cases  where  intuba- 
tion fails,  as  when  the  membrane  extends  down  low  in  the  trachea, 
and  where  the  attending  physician  does  not  possess  the  necessary 
skill  for  intubation,  or  where  the  necessary  instruments  for  intubation 
are  not  available.  Tracheotomy  may  also  be  required  for  the 
removal  of  foreign  bodies  from  the  larynx,  trachea,  and  bronchi,  for 
the  administration  of  tracheal  anesthesia  in  operations  upon  the 



mouth,  pharynx,  jaws,  or  larynx,  and  as  a  preliminary  to  laryngect- 
omy and  lower  tracheo-bronchoscopy. 

Choice  of  Operation. — The  choice  between  laryngotomy,  high 
tracheotomy,  and  low  tracheotomy  depends  upon  the  seat  of  the 
obstruction  and  also  upon  the  age  of  the  patient  and  the  necessity  for 
haste.  Of  the  three,  laryngotomy  is  the  most  easily  and  rapidly 
performed.  It  thus  becomes  the  operation  of  choice  in  a  sudden 
emergency  where  the  obstruction  is  located  in  the  larynx  and  where 
there  is  demand  for  haste  in  order  to  avoid  imminent  suffocation  or 
where  the  proper  instruments  and  assistants  are  lacking.     It  is  not, 

Pig.  446. — The  location  of  the  incisions  in  laryngotomy  and  tracheotomy.      (After 

a.  Thyroid  cartilage;  h,  incision  for  laryngotomy;  c  and  e,  branches  of  superior 
thyroid  arteries;  d,  cricoid  cartilage;/,  incision  for  high  tracheotomy;  g,  thyroid 
gland;  }i,  incision  for  low  tracheotomy;  ?,  pneumogastric  nerve;  j,  sterno-mastoid 
muscle;  k,  inferior  thyroid  veins;  /,  sterno-thyroid  muscle. 

however,  a  suitable  operation  to  be  performed  upon  those  under 
thirteen  years  of  age,  on  account  of  the  small  size  of  the  cricothyroid 
space,  nor  should  it  be  performed  for  the  relief  of  conditions  requiring 
the  wearing  of  a  tube  for  any  length  of  time,  on  account  of  the  proxim- 
ity of  the  vocal  cords  and  their  liabiHty  to  injury  by  the  tube. 

On  account  of  the  small  number  of  important  vessels  encountered, 
and  the  greater  ease  with  which  the  trachea  is  reached,  high  tracheot- 
omy is  preferable  to  the  low  operation  where  the  location  of  the 
trouble  permits.  It  is  the  operation  of  choice  for  children  and  in 
cases  of  diphtheria  where  a  tube  has  to  be  worn  for  some  time. 



Low  tracheotomy  may  be  required  for  the  removal  of  foreign  bod- 
ies from  the  bronchi,  for  lower  tracheo-bronchoscopy,  for  the  relief 
of  threatened  suffocation  from  occlusion  of  the  trachea  by  tumors  of 
the  thyroid,  etc.  It  requires  more  skill  in  its  performance  than  does 
the  high  operation,  as  in  the  lower  portion  of  the  neck  the  trachea  is 
more  deeply  placed  and  important  structures  at  the  root  of  the  neck 
are  in  close  proximity. 

Instruments. — The  instruments  that  should  be  provided  include: 
a  scalpel,  a  narrow  bistoury,  scissors,  two  sharp  retractors,  two  ten- 


Fig.  447.^Instruments  for  tracheotomy. 
I,  Scalpel;  2,  curved  bistoury;  3,  scissors;  4,  retractors;  5,  tenaculum;  6, artery 
clamps;  7,  thumb  forceps;  8,  needle-holder;  9,  Trousseau  tracheal  dilator;  10,  tra- 
cheotomy tube;  II,  catheter;  12,  tracheal  forceps;  13,  needles;  14,  No.  2  catgut. 

acula,  artery  clamps,  two  pairs  of  thumb  forceps,  tracheal  forceps,  a 
Trousseau  tracheal  dilator,  a  flexible-rubber  catheter,  tracheotomy 
tubes  and  tape,  a  needle-holder,  two  curved  cutting-edge  needles,  and 
No.  2  catgut  for  ligatures  and  sutures  (Fig.  447).  In  an  emergency, 
where  delay  would  mean  the  loss  of  the  patient's  life,  the  operation 
may  be  performed  by  the  aid  of  a  pocket-knife  and  two  hairpins  bent 
in  the  shape  of  a  hook  to  hold  the  trachea  open  until  the  proper  tube 
can  be  obtained. 



Tracheotomy  tubes  of  several  sizes  and  with  different  curves 
should  be  provided  so  that  one  suitable  for  the  individual  case  may  be 
at  hand.  A  silver  tube,  somewhat  flattened  from  side  to  side,  with- 
out fenestrae,  and  with  a  movable  inside  tube,  is  preferable  (Fig.  448). 

Fig.  448. — Tracheotomy  tube. 

Fig.  449. — Tracheotomy  tube  improvised 
from  rubber  tubing. 

With  some  tubes  an  obturator  is  supplied  as  an  aid  to  insertion.  For 
an  adult,  a  No.  5  or  6  tube  will  usually  suffice;  for  a  child  under  two, 
a  No.  2  tube  should  be  provided;  for  a  child  from  two  to  four,  a 
No.  3;  and  for  one  over  four,  a  No.  4.     In  an  emergency  a  tube  may 

Fig.   450. — Position  of  patient  for  laryngotomy  and  tracheotomy. 

be  improvised  by  bending  a  piece  of  rubber  tubing  into  the  required 
shape,  as  shown  in  Fig.  449.  For  laryngotomy,  a  tube  shorter  than 
the  ordinary  tracheotomy  tube,  and  flattened  from  before  backward, 
is  employed. 

Asepsis. — The  instruments  are  sterilized  by  boiling  or,  in  an  emer- 
gency, by  immersion  in  a  i  to  20  carbolic  acid  solution.     The  hands 


of  the  operator  and  his  assistants  shouki  be  prepared  with  the  same 
care  as  for  any  operation. 

Position  of  the  Patient. — This  should  be  such  as  to  bring  the  neck 
into  the  greatest  possible  prominence.  The  patient  is  therefore 
placed  in  a  strong  light  on  a  firm  flat  table  with  a  cushion  under  his 
shoulders,  thus  allowing  the  head  to  hang  back,  but  not  so  far  as  to 
put  the  trachea  under  tension  or  to  flatten  it  and  impede  respiration 
(Fig.  450).  In  an  emergency,  the  patient's  head  may  be  simply 
alowed  to  hang  over  the  edge  of  the  table  or  a  lounge. 

A  child  should  be  wrapped  in  a  blanket  or  sheet,  with  its  arms  at 
the  sides.  The  legs  should  also  be  secured  and  an  assistant  should  be 
provided  to  hold  the  head  in  proper  position. 

Anesthesia. — In  adults,  local  anesthesia  with  cocain  or  novocain 
is  sufficient.  A  0.2  per  cent,  solution  of  cocain  is  employed  for  the 
skin,  and  a  o.i  per  cent,  solution  for  deeper  infiltration.  When  there 
is  occasion  for  great  haste  in  the  presence  of  unconsciousness  or  dys- 
pnea with  marked  and  increasing  cyanosis,  an  anesthetic  may  be 
dispensed  with,  as  in  such  cases  the  sense  of  pain  is  much  blunted  or 

In  young  children,  local  anesthesia  is  not  followed  by  good  results, 
as  the  infiltration  alone  terrifies  the  child  and  produces  struggling, 
which  adds  to  the  dyspnea.  If  air  enters  the  lungs  at  all,  chloroform 
given  slowly  is  the  best  anesthesia,  ether  being  apt  to  irritate  the 
mucous  membrane  and  produce  laryngeal  spasm,  thus  adding  to  the 

Preparations. — If  hairy,  the  neck  should  be  shaved.  The  skin  is 
sterilized  by  painting  with  tincture  of  iodin. 

Technic. — i.  Laryngotomy. — The  thyroid  and  cricoid  cartilages 
are  identified,  and,  with  the  larynx  supported  between  the  thumb  and 
forefinger  of  the  operator's  left  hand,  an  incision  about  i  1/2  inches 
(4  cm.)  long  is  made  through  the  skin,  exactly  in  the  median  line  of 
the  neck,  extending  from  the  lower  portion  of  the  thyroid  cartilage  to 
below  the  cricoid  cartilage.  The  superficial  fascia,  platysma,  and 
deep  fascia  are  divided,  and  the  sternohyoid  and  sternothyroid  mus- 
cles are  separated  at  the  inner  borders  and  held  apart  by  retractors. 
The  connective  tissue  and  veins  underlying  these  structures  are  then 
separated,  all  veins  being  clamped  or  hgated  before  division.  The 
cricothyroid  membrane  is  thus  brought  into  view.  The  thyroid 
cartilage  is  steadied  with  a  tenaculum,  while  the  cricothyroid 
membrane  is  transversely  incised  by  means  of  a  sharp,  narrow-pointed 
bistoury  near  the  upper  border  of  the  cricoid  cartilage,  so  as  to  avoid 



the  cricothyroid  artery,  which  runs  along  the  upper  border  of  the 
space  below  the  thyroid  cartilage  (Fig.  451).  If  the  situation  of  this 
vessel  is  such  that  injury  to  it  or  its  branches  cannot  be  avoided,  it 
should  be  tied  between  two  ligatures  before  the  membrane  is  incised. 
In  opening  the  membrane,  the  incision  must  be  carried  deep  enough 
to  include  the  mucous  membrane  lining  it,  otherwise  the  laryngotomy 
tube  may  be  pushed  in  between  the  two  structures  and  not  into  the 
larynx  at  all.  The  wound  is  held  apart  with  two  small  retractors  or 
a  tracheal  dilator,  and  the  foreign  body  which  may  be  causing  the 
obstruction  is  removed  by  means  of  tracheal  forceps.  If  there  is  not 
sufficient  room  to  remove  the  foreign  body  through  this  incision,  the 

Fig.  451. — Opening  the  cricothyroid  membrane  in  laryngotomy. 
(After  Bickham.) 

cricoid  cartilage  may  be  cut.  The  laryngotomy  tube  is  then  care- 
fully introduced  and  is  secured  in  place  by  tapes  passing  around  the 
patient's  neck,  a  small  square  pad,  split  to  its  center,  being  interposed 
between  the  skin  and  the  flange  of  the  tube.  A  stitch  or  two  may  be 
placed  at  the  upper  and  lower  angles  of  the  wound  to  bring  them  to- 
gether, if  necessary.  Even  where  the  obstruction  is  immediately 
relieved,  it  is  preferable  in  any  case  to  insert  a  tube  for  a  time  until  the 
tissues  become  more  or  less  adherent,  so  as  to  avoid  subcutaneous 

2.  High  Tracheotomy. — The  thyroid  cartilage  is  grasped  between 
the  thumb  and  forefinger  of  the  left  hand,  so  as  to  steady  the  trachea, 
and  with  the  right  hand  a  vertical  incision  i  1/2  to  2  inches  (4  to  5 



cm.)  long  is  made  exactly  in  the  median  line,  extending  from  the  cri- 
coid cartilage  to  a  Uttle  below  the  isthmus  of  the  thyroid  gland  (Fig. 
452).  The  skin  and  superficial  and  deep  fascia  are  incised,  and  the 
anterior  jugular  veins  which  are  encountered  in  the  upper  part  of  the 
incision,  together  with  any  communicating  branches  of  the  superior 
thyroid  veins,  are  caught  in  forceps  and  ligated.  The  sternohyoid 
and  sternothyroid  muscles  are  thus  exposed,  and  should  be  separated 
along  their  inner  borders  and  retracted  to  the  ?ides.  As  these  luscles 
are  pulled  apart,  the  isthmus  of  the  thyroid  gland  and  the  deep  cervi- 
cal fascia  covering  the  trachea  appear.  This  fascia  is  then  divided 
from  the  lower  border  of  the  cricoid  cartilage  by  a  transverse  incision 
curved  downward  at  the  extremities.  The  fascia  is  then  stripped 
from  the  trachea  and  retracted  dow^nward,  and  with  it  the  isthmus  of 
the  thyroid  gland,  thus  exposing  the  rings  of  the  trachea.     If  the 

Fig.  452. — Exposing  the  trachea  in  high  tracheotomy. 

thyroid  isthmus  is  very  large,  two  Hgatures  may  be  placed  about  it,  on 
each  side  of  the  median  line,  to  control  the  hemorrhage,  and  the  isth- 
mus with  the  deep  fascia  is  incised  vertically  and  retracted  to  each 
side.  A  tenaculum  is  then  inserted  beneath  the  cricoid  cartilage,  and 
is  held  by  an  assistant  so  as  to  steady  the  trachea.  If  without  a  tube, 
it  is  well  to  apply  retraction  sutures  on  either  side  of  the  trachea  before 
opening  the  latter.  For  this  purpose  a  full  curved  needle,  threaded 
with  fairly  strong  silk,  is  passed  on  each  side  through  the  membrane 
below  the  ring  to  be  cut,  emerging  through  the  membrane  above.     A 



sharp  narrow  bistoury,  with  its  cutting  edge  up,  is  inserted  through 
the  membrane  below  the  second  ring  of  the  trachea,  and  the  latter  is 

Fig.  453. — Opening  the  trachea  in  high  tracheotomy.     (After  Bickham.) 

Fig.  454. — Method  of  inserting  the  tracheotomy  tube. 

incised  in  the  median  line  as  far  up  as  the  cricoid  cartilage,  care  being 
taken  to  include  the  mucous  membrane  of  the  trachea  in  this  incision 



(Fig.  453).  The  edges  of  the  tracheal  opening  are  separated  with 
tracheal  forceps,  or  the  wound  is  held  open  by  the  retraction  sutures, 
if  they  were  previously  inserted,  and  the  tracheotomy  tube,  with  its 
cannula,  is  carefully  passed  through  the  open  wound  into  the  trachea 
(Fig.  454).  If  there  is  no  great  urgency,  all  bleeding  should  be 
arrested  before  the  trachea  is  opened,  but  where  haste  is  important 
this  may  be  omitted  until  the  tube  is  introduced. 

When  the  tube  has  been  properly  placed,  a  pad  of  gauze  is  inter- 
posed between  the  skin  and  the  flange  of  the  tube,  and  the  latter  is 
securely  held  in  place  by  tapes  passing  from  each  side  of  the  flange 
around  the  neck  (Fig.  455). 

In  cases  of  diphtheria,  as  soon  as  the  trachea  is  opened  a  large 
amount  of  mucus  and  membrane  is  usually  expelled,  and  it  is  of 
advantage  in  such  cases  not  to  insert  the  tube  at  once,  but  to  hold  the 

Fig.  455. — Showing  the  tracheotomy  tube  in  place.      (Stoney.) 

tracheal  wound  open  and  allow  the  membrane  to  be  expelled.  What 
is  not  expelled  may  then  be  removed,  if  loose,  by  forceps.  The  dan- 
ger of  infection  from  the  patient's  coughing  bits  of  membrane  from 
the  tracheal  opening  into  the  face  of  the  operator  should  be  guarded 
against  by  the  operator  wearing  a  face  mask  or  by  holding  a  piece  of 
wet  gauze  over  the  wound. 

3.  Low  Tracheotomy. — The  trachea  is  steadied  with  the  thumb 
and  forefinger  of  the  left  hand,  and  a  vertical  incision  is  carried  from 
the  thyroid  cartilage  to  within  1/2  inch  (i  cm.)  of  the  sternal  notch. 
The  skin  and  superficial  and  deep  fascia  are  incised,  and  the  inferior 
thyroid  veins,  or  other  vessels  that  may  be  in  the  way,  are  ligated  and 


divided.  The  sternohyoid  and  sternothyroid  rmiscles  are  separated 
in  the  median  line  and  are  retracted  to  each  side.  The  deep  cervical 
fascia  is  divided  vertically  downward  from  the  lower  border  of  the 
isthmus  of  the  thyroid  gland,  and  is  retracted  laterally,  notching  it 
transversely  on  each  side  if  necessary  to  obtain  more  space.  Care 
must  be  taken  in  deepening  the  incision  at  the  lower  angle  of  the 
wound  not  to  injure  the  innominate  vein  which  may  bulge  up  above 
the  sternal  notch.  The  isthmus  of  the  thyroid  gland  is  pulled  well  up 
out  of  the  way  by  means  of  a  retractor,  and  while  the  trachea  is 
steadied,  an  incision  is  carried  upward  through  two  or  more  of  the 
lowermost  rings  by  means  of  a  narrow  bistoury.  The  edges  of  the 
tracheal  wound  are  then  retracted,  and  the  tube  is  inserted  and 
secured  in  place  as  previously  described. 

After-care. — The  opening  of  the  tube  should  be  covered  with  a 
piece  of  gauze  moistened  with  normal  salt  solution,  and  the  patient 

Fig.  456. — Intracannular  alligator  forceps.     (Fowler.) 

kept  in  a  room  at  a  temperature  of  about  65°  to  70°  (18°  to  21°  C). 
If  the  operation  is  performed  for  inflammatory  conditions,  the  atmos- 
phere should  be  kept  moist  by  the  steam  from  a  croup  kettle  directed 
so  as  to  play  over  the  tracheal  opening  (see  page  412).  At  first,  the 
inner  tube  should  be  removed  every  two  or  three  hours  and  be 
cleansed;  later,  less  frequent  attention  will  be  required.  The  outer 
tube  should  be  removed  and  cleansed  as  often  as  necessary,  this  being 
done  by  the  surgeon  himself.  Its  reintroduction  will  be  greatly  facili- 
tated by  the  use  of  a  guide.  Any  membrane  or  mucus  that  may  col- 
lect at  the  mouth  of  the  tube  should  be  promptly  removed.  Secre- 
tions blocking  the  tube  may  be  removed  by  means  of  a  small  catheter 
and  a  suction  syringe.  Membrane  may  be  removed  from  the  interior 
of  the  tube  with  alHgator  forceps  (Fig.  456)  introduced  through  the 
cannula.  If  this  is  not  possible,  the  tracheotomy  tube  should  be  with- 
drawn and  the  obstruction  removed. 

Removal  of  the  Tube. — In  cases  of  diphtheria  the  tube  may  be 
permanently  removed  as  soon  as  there  is  free  respiration  through  the 


larynx  with  the  tracheal  wound  closed.  This  is  usually  possible  in 
from  five  days  to  one  week.  When  tracheotomy  is  employed  for 
the  removal  of  foreign  bodies,  etc.,  the  tube  should  be  worn  for 
twenty-four  hours  at  least.  This  allows  time  for  the  oozing  to  cease 
and  averts  the  danger  of  blood  entering  the  trachea  and  the  escape  of 
air  into  the  subcutaneous  tissues. 

Complications. — Broncho-pneumonia  is  a  common  complication 
even  when  not  due  to  an  extension  of  the  diphtheritic  process.  Infec- 
tion of  the  wound  may  follow  in  diphtheria  cases  and  may  spread  into 
the  loose  connective  tissue  of  the  neck,  producing  a  cellulitis;  or  the 
infection  may  work  down  and  cause  septic  pneumonia.  An  improp- 
erly fitting  tube  frequently  causes  ulceration  of  the  trachea  from 
pressure.  This  complication  should  be  immediately  remedied  by  the 
substitution  of  a  new  tube.  Emphysema  may  occur  if  the  tube  is 
removed  too  soon;  it  has  also  been  produced  from  injury  to  the  pos- 
terior or  lateral  walls  of  the  trachea.  Hemorrhage  from  congested 
veins  may  at  times  be  severe;  in  the  majority  of  cases,  however,  the 
bleeding,  which  may  be  profuse  before  the  trachea  is  opened,  stops 
spontaneously  as  soon  as  respiration  is  re-established. 


A natomic  Considerations 

The  esophagus  extends  from  the  lower  border  of  the  cricoid  cartil- 
age to  about  the  level  of  the  ensiform  cartilage  or,  in  other  words, 
from  the  level  of  the  disk  between  the  fifth  and  sLxth  cervical  verte- 
bras to  the  tenth  dorsal  vertebra.  Its  entire  length  is  about.  lo  inchs- 
(25  cm.),  while  the  distance  from  the  upper  incisor  teeth  to  the  cardiac 
end  measures  about  16  inches  (40  cm.) .  Antero-posteriorly  the  esoph- 
agus presents  a  slight  curve  with  the  concavity  forward,  as  it  fol- 
lows the  direction  of  the  spinal  column.  Laterally,  it  has  the  follow- 
ing curves:  from  its  starting  point  it  turns  slightly  to  the  left, 
projecting  as  much  as  1/2  inch  (i  cm.)  to  the  left  of  the  trachea;  it 
then  descends  in  front  of  the  spine,  at  first  behind  the  arch  of  the  aorta 
and  then  lying  to  the  right  of  the  aorta,  finally  curving  in  front  of,  and 
a  little  to  the  left  of,  the  aorta  to  pass  through  the  diaphragm  (Fig. 
457).  In  its  course,  the  esophagus  has  in  front  of  its  upper  portion 
the  trachea;  while  below  it  is  crossed  by  the  left  bronchus  and  the 
arch  of  the  aorta.  The  pericardium  and  the  left  vagus  nerve  also 
lie  in  front.  Posteriorly,  it  rests  upon  the  spinal  column  and  the  tho- 
racic duct;  about  3  inches  (7  cm.)  from  the  diaphragm  it  crosses  the 
aorta.     On  either  side  it  is  in  relation  with  the  pleura. 

The  esophagus  measures  about  3/4  inch  (19  mm.)  in  diameter, 
but  a  number  of  constrictions  in  its  caHber  have  been  described,  the 
most  marked  being  as  follows:  (i)  at  its  commencement,  6  inches 
(15  cm.)  from  the  incisor  teeth;  (2)  at  a  point  10. inches  (25  cm.) 
from  the  incisor  teeth,  where  it  is  crossed  by  the  left  bronchus;  and 
(3)  at  a  point  16  inches  (40  cm.)  from  the  incisor  teeth,  where  it 
passes  through  the  diaphragm  (Fig.  458).  At  these  points  the  caKber 
of  the  tube  measures  about  1/2  inch  (i  cm.).  The  measurements, 
curves,  and  constrictions  of  the  esophagus  are  important  to  remember 
in  the  passage  of  instruments  and  with  reference  to  the  lodgment  of 
foreign  bodies. 




Diagnostic   Methods 

The  methods  available  for  examination  of  the  esophagus  include : 
(i)  auscultation,  (2)  percussion,  (3)  external  palpation,  (4)  instru- 
mental examination,  (5)  inspection  through  the  esophagoscope,  and 
(5)  the  use  of  the  X-rays.     The  first  three  of  these  methods  are  of 

Fig.  457.  Fig.  458. 

Fig.  457. — The  course  and  relations  of  the  esophagus  viewed  from  behind. 

Fig.  458. — The  normal  narro wings  of  the  esophagus.  (Eisendrath.)  i,  At 
its  junction  with  the  pharynx;  2,  opposite  the  bifurcation  of  the  bronchi;  3,  at 
the  diaphragm. 

very  limited  cUnical  value,  while  the  use  of  the  esophagoscope  is  of 
doubtful  value  except  in  the  hands  of  an  expert,  so  that  in  the  major- 
ity of  cases  we  have  to  rely  upon  the  use  of  bougies  and  sounds  or  the 

As  in  examination  of  other  regions,  a  careful  history  of  the  case 
should  precede  any  local  examination. 



Auscultation  is  performed  by  listening  with  a  stethoscope  over  the 
course  of  the  esophagus  while  the  patient  swallows  liquids.  The 
usual  points  for  auscultation  are  upon  the  left  side  of  the  spine  oppo- 
site the  ninth  or  tenth  dorsal  vertebra,  or  just  to  the  left  of  the  ensi- 
form.  Normally,  during  the  passage  of  liquids  down  the  tube  two 
sounds  are  heard:  one  directly  after  the  patient  swallows  and  the 
other  six  or  seven  seconds  later,  as  the  food  is  forced  into  the  stomach 
through  the  cardia.  If  stenosis  exists  at  the  cardia  or  a  stricture  be 
present  at  some  point  higher  up,  this  second  sound  will  be  absent  or 
delayed;  in  paralysis  of  the  esophagus  it  will  likewise  be  absent.  At 
times  it  may  also  be  possible  to  recognize  by  auscultation  the  stop- 
page of  the  fluid  when  it  reaches  the  point  of  stricture. 


Percussion  may  reveal  the  presence  of  large  tumors,  dilatations,  or 
diverticula.  In  the  latter  condition,  dulness  may  be  present  only 
after  eating  and  be  absent  when  the  sac  is  empty.  A  tympanitic 
note  will  be  obtained  when  the  diverticulum  sac  contains  gas. 


External  palpation  is  extremely  limited  in  usefulness,  as  it  is  only 
applicable  to  the  cervical  portion  of  the  esophagus.  By  means  of 
palpation  one  may  be  able  to  discover  hard  foreign  bodies,  tumors, 
enlarged  glands,  enlargements  of  the  thyroid,  as  well  as  any  pressure 
tenderness  along  the  esophagus.  Diverticula  full  of  food  may  be  thus 
distinguished  and  mapped  out,  and  not  infrequently  it  is  possible  to 
empty  the  diverticulum  sac  of  its  contents  by  pressure. 

By  internal  palpation  with  the  index-finger,  foreign  bodies  lodged 
in  the  entrance  of  the  esophagus  and  strictures,  new  growths,  etc., 
at  the  same  location  may  be  recognized. 


The  sound  and  bougie  are  employed  for  diagnostic  as  well  as  thera- 
peutic purposes.  By  their  use  valuable  information  may  be  obtained 
as  to  the  location  of  foreign  bodies,  strictures,  diverticula,  etc. ;  fur- 
thermore, the  degree  of  a  stenosis  may  be  accurately  determined. 
The  passage  of  esophageal  instruments  is  not  difficult.     Gentleness 


only  should  be  employed  in  manipulation,  however,  since,  if  due  care 
is  not  exercised  in  this  direction,  false  passage  may  be  readily  made 
through  the  esophagus  into  the  rnediastinum;  especially  is  such  an 

Fig.   459. — Cylindrical  esophageal  sound. 

accident  possible  if  the  coats  of  the  esophagus  are  already  weakened 
by  disease. 

Before  any  attempt  is  made  to  pass  instruments,  a  thorough  phys- 
ical examination — including  the  vascular  system — should  be  made. 
In  the  presence  of  aortic  aneurysm,  recent  hemorrhage  from  the  esoph- 
agus or  stomach,  acute  inflammation  of  the  esophagus,  and  after 

Fig.  460. — Conical  esophageal  sound. 

recent  ulceration,  the  use  of  esophageal  instruments  is  contraindi- 
cated.  In  cases  of  advanced  pulmonary  or  cardiac  disease  and  cir- 
rhosis of  the  liver,  instruments,  if  used,  should  be  employed  with 
great  caution. 

Instruments. — For  ordinary  examination,  graduated  esophageal 
bougies  and  bougies  a  boule  are  employed.     These  instruments  vary 

Fig.  461. — Olivary  bougies  a  boule  for  the  esophagus. 

in  length  from  24  to  32  inches  (60  to  80  cm.).  The  best  bougies  are 
hollow  and  are  made  of  a  gum-elastic  material,  so  that  when  warmed 
they  become  flexible  and  capable  of  being  bent  to  any  desired  shape. 

They  may  be  obtained  cylindrical  (Fig.  459)  or  conical  (Fig.  460)  in 
form.  In  their  stead,  however,  a  thick  rubber  stomach-tube  is  often 

The  bougie  a  boule  is  an  essential  instrument  if  the  length  of  a 
stricture  is  to  be  estimated.     It  consists  of  a  flexible  whalebone  shaft, 



to  the  end  of  which  metal  or  ivory  oKve-shaped  tips  of  different  sizes 
may  be  screwed  (Fig.  461).  The  shaft  should  be  marked  oil  in  an 
inch  or  centimetric  scale. 

In  cases  of  very  tight  stricture  filiform  bougies  of  whalebone  or 
woven  material  may  be  employed  to  determine  whether  the  stricture 
is  at  all  permeable.  They  may  be  introduced  into  the  stricture 
through  a  hollow  bougie  which  is  first  passed  to  the  face  of  the  stric- 
ture, or  they  may  be  inserted  through  an  esophagoscope. 

Asepsis. — Rubber  bougies  and  tubes  may  be  sterilized  by  boiling. 
The  gum-elastic  instruments,  unless  of  the  very  best  material,  are 
ruined  by  boiling  or  by  the  use  of  strong  antiseptics.  They  may  be 
rendered  sufficiently  aseptic  by  immersion  in  a  saturated  solution  of 

Fig.  462. — Shows  the  first  step  in  introducing  an  esophageal  bougie. 

boracic  acid,  after  first  thoroughly  washing  with  soap  and  water. 
The  hands  of  the  operator  should  also  be  clean. 

Position. — The  patient  is  seated  in  a  chair  with  the  head  thrown 
back  against  the  back  of  the  chair,  and  with  the  chin  raised  sufficiently 
to  make  the  passage  between  the  mouth  and  the  esophagus  as  straight 
a  line  as  is  possible.  The  surgeon  stands  in  front  of  the  patient, 
while,  if  desired,  an  assistant  may  steady  the  head  from  behind.  In 
the  case  of  a  child,  it  will  be  necessary  to  confine  its  arms,  either  hav- 
ing them  held  by  a  nurse  or  by  including  them  in  a  sheet  wrapped 
about  the  child's  body. 

Anesthesia. — In  an  adult  general  anesthesia  is  only  necessary  in 
exceptional  cases,  but  the  pharynx  and  larynx,  if  very  irritable  or  sen- 



sitive,  may  be  brushed  over  with  a  5  or  lo  per  cent,  solution  of  cocain. 
Technic. — The  patient  is  seated  in  the  proper  position  with  a  towel 
about  the  neck  for  protection,  and  is  given  a  basin  to  catch  vomitus  or 
saliva.  A  soft,  flexible  sound  is  passed  as  follows:  the  bougie, 
moistened  with  water  and  held  in  the  operator's  right  hand  as  one 
would  a  pen,  is  passed  into  the  patient's  open  mouth  back  to  the  phar- 
ynx. The  patient  is  then  requested  to  swallow  and  the  instrument  is 
thus  advanced,  partly  by  the  act  of  swallowing  and  partly  by  the 

Fig.  463. — Introduction  of   an   esophageal  bougie  with   the   finger  holding  the 
tongue  and  epiglottis  forward. 

operator,  until  an  obstruction  is  reached  or  the  sound  enters  the 
stomaxh  (Fig.  462). 

Sometimes  when  a  rather  inflexible  bougie  is  employed  or  when  the 
tongue  is  thick  or  the  pharynx  is  swollen,  some  difficulty  may  be 
encountered  in  entering  the  esophageal  opening.  Under  such  con- 
ditions the  operator  passes  the  index-finger  of  his  left  hand  into  the 
patient's  widely  opened  mouth  to  a  point  well  back  of  the  tongue  and 
draws  the  latter  forward,  and  with  it  the  larynx,  so  that  the  esophagus 
may  be  more  easily  entered  (Fig.  463).  The  bougie  is  then  passed 
on  the  finger  as  a  guide  straight  back  in  the  median  line  to  the 



pharynx,  and,  hugging  the  posterior  wall  of  the  pharynx,  it  is  pushed 
steadily,  but  gently,  backward  and  downward  into  the  esophagus,  and 
thence  into  the  stomach,  unless  some  obstruction  be. encountered. 

The  patient  should  be  instructed  to  breathe  deeply  during  the 
passage  of  the  bougie,  even  if  gagging  is  produced,  and  he  should  be 
cautioned  not  to  bite  the  examiner's  finger  or  the  tube.  There  will 
usually  be  gagging  and  some  attempts  to  vomit  as  the  tube  is  inserted, 
but,  unless  very  distressing,  they  may  be  disregarded.  The  patient's 
head,  however,  should  be  bent  forward  over  a  basin  as  soon  as  the 
tube  is  well  within  the  esophagus  to  receive  any  vomitus,  mucus,  or 
saliva  (Fig.  464). 

If  dyspnea  and  cough  are  induced,  the  instrument  has  probably 
entered  the  larynx.     To  settle  this  point,  the  patient  should  be  told  to 

Fig.  464. — Shows  the  second  step  in  introducing  an  esophageal  bougie. 

phonate  "ee";  if  he  can  do  so,  one  may  be  sure  the  bougie  is  not  in 
the  larynx.  If  the  passage  of  the  tube  becomes  impeded  at  any  point, 
the  tube  should  be  slightly  withdrawn  and  then  again  pushed  gently 
onward,  when,  unless  a  stenosis  exists,  it  will  advance  without 
difficulty.  The  points  of  normal  constriction  at  which  a  bougie  may 
be  arrested  without  any  diseased  condition  being  present  should,  how- 
ever, be  kept  in  mind.  They  are:  (i)  6  inches  (15  cm.)  from  the 
upper  incisor  teeth;  (2)  10  inches  (25  cm.)  from  the  incisors;  and  (3) 
16  inches  (40  cm.)  from  the  incisors  (see  Fig.  458).  If  a  large  tube 
can  be  passed  into  the  stomach,  the  existence  of  a  stenosis  may  be 
ruled  out,  while  if  the  tube  passes  very  easily  without  any  sense  of 
resistance,  atony  or  paralysis  of  the  canal  is  presumable. 



Any  evidences  of  pain,  however,  produced  by  the  bougie  in  its 
descent  should  be  carefully  noted,  as  pointing  to  possible  inflamma- 
tion, ulceration,  or  malignancy.  When  the  bougie  meets  a  real 
obstruction  the  cause  should,  if  possible,  be  learned;  that  is,  whether 
due  to  spasm,  an  organic  stricture,  a  diverticulum,  a  new  growth,  or  a 
foreign  body.  No  force  should  be  employed  in  attempting  to  over- 
come the  obstruction,  but  the  bougie  should  simply  be  held  firmly  in 
place  for  several  minutes  or  be  slightly  withdrawn  when,  if  a  spasm 
were  the  cause,  it  can  be  advanced  as  relaxation  takes  place.  A  spas- 
modic stricture  will  always  disappear  if  the  patient  is  placed  under  the 
influence  of  a  general  anesthetic.     If  the  obstruction  does  not  yield, 

Fig.  465.  Fig.  466. 

Fig.  465. — Method  of  estimating  the  length  of  an  esophageal  stricture.  The 
bougie  a  boule  at  the  face  of  the  stricture. 

Fig.  466. — Method  of  estimating  the  length  of  an  esophageal  stricture.  The 
bougie  a  boule  is  withdrawn  until  its  base  is  arrested  at  the  distal  end  of  the 

the  bougie  is  removed  and  a  smaller  one  is  inserted;  and,  if  necessary, 
smaller  sizes  are  successively  introduced  until  one  is  selected  that  will 
pass  completely  through  the  stenosed  area  into  the  stomach.  In  this 
way  the  degree  of  stenosis  is  ascertained.  It  is  quite  important  in 
making  this  examination  to  insert  the  bougie  into  the  stomach,  as, 
otherwise,  a  second  stricture  below  the  first  may  be  overlooked. 

To  determine  the  length  of  a  stricture,  a  large  olive-tipped  sound 
is  inserted  until  it  reaches  the  face  of  the  stricture  (Fig.  465),  and  the 



distance  of  the  stenosis  from  the  upper  incisor  teeth  is  estimated  from 
the  markings  on  the  shaft  of  the  instrument.  The  bougie  is  then 
withdrawn  and  a  size  that  will  just  pass  is  inserted  well  through  the 
stricture.  Upon  withdrawing  the  instrument,  the  base  of  the  bulb 
catches  in  the  lower  rim  of  the  constriction  (Fig.  466),  and  the  dis- 
tance of  this  point  from  the  mouth  is  also  estimated.  By  subtracting 
the  first  of  these  measurements  from  the  second,  the  length  of  the  con- 
tracture is  readily  determined. 

It  is  often  possible  for  a  practised  hand  to  determine  the  consis- 
tency of  an  obstruction  from  the  sensation  imparted  by  contact  with 

Fig.  467.  Fig.  468.  Fig.  469. 

FiF.  467. — Shows  a  sound  passing  the  opening  of  a  diverticulum.  (After 

Fig.  468. — Shows  the  ease  with  which  a  sound  will  enter  a  diverticulum  when 
the  latter  is  full.     (After  Gumprecht.) 

Fig.  469. — Shows  the  ease  with  which  a  sound  follows  the  esophagus  when 
the  diverticulum  is  empty.     (After  Gumprecht.) 

the  tip  of  the  instrument.  By  means  of  a  metal-tipped  bougie  a  boule 
the  consistency  of  hard  foreign  bodies,  such  as  teeth,  coins,  bone,  etc., 
may  be  readily  recognized,  and  at  times  a  distinct  sound  may  be 
distinguished  when  the  two  come  in  contact. 

If  the  bougie  has  entered  a  diverticulum,  it  wiU  be  possible  to 
move  its  end  freely  in  difi'erent  directions,  and,  if  the  diverticulum  be 
located  high  up,  the  end  of  the  bougie  may  often  be  felt  in  the  neck. 
Again,  by  withdrawing  the  instrument  somewhat  so  as  to  disengage 
the  tip,  and  by  changing  its  direction  (Fig.  467),  it  can  frequently  be 
passed  by  the  diverticulum  into  the  stomach.     A  bougie  will  be  more 



apt  to  enter  a  diverticulum  if  the  sac  be  full  (Fig.  468)  and  pass  to  the 
stomach  when  the  sac  'is  empty  (Fig.  469).  This  intermittent 
obstruction  to  the  passage  of  a  bougie  is  characteristic  of  a  diverticu- 
lum, and  is  a  point  in  the  differential  diagnosis  from  stricture. 
Another  method  of  differentiating  between  a  stenosis  and  a  diver- 
ticulum has  been  devised  by  Plummer,  It  is  carried  out  as  follows: 
The  patient  is  instructed  to  swallow  with  a  little  water  before 
bedtime  3  yards  (270  cm.)  of  button-hole  silk  and  in  the  morning  to 
swallow  3  yards  (270  cm.)  more  at  the  rate  of  a  foot  (30  cm.)  an  hour. 
By  the  afternoon  of  the  same  day,  if  there  is  an  opening  in  the  stric- 
ture or  diverticulum,  the  thread  will  have  been  carried  into  the  stom- 

FiG.  470.  Fig.  471. 

Fig.  470. — Esophageal  sound  passed  over  a  swallowed  thread  into  a  diverti- 
culum.    (After  Plummer.) 

Fig.  471. — Sound  lifted  _  out  of  the  diverticulum  by  tightening  the  thread. 
(After  Plummer.) 

ach  and  intestines  a  sufficient  distance  to  withstand  moderate  trac- 
tion without  being  withdrawn.  A  whalebone  bougie  with  an  olive 
tip,  through  which  is  an  opening  sufficiently  large  to  acconunodate  the 
thread,  is  then  passed  down  the  esophagus  on  the  thread,  which  is 
held  loosely,  until  an  obstruction  is  encountered.  If  this  obstruction 
be  due  to  stricture,  the  bougie  will  not  change  its  level  when  the 
thread  is  made  taut,  but,  if  the  sound  is  in  a  diverticulum  (Fig.  470), 
the  bougie  will  be  elevated  to  the  level  of  the  opening  into  the  esoph- 
agus (Fig.  471).  The  depth  of  the  diverticulum  may  be  readily 
determined  by  the  distance  the  bougie  is  elevated  when  the  thread  is 
made  taut. 


The  bougie  should  always  be  examined  after  its  withdrawal  for 
the  presence  of  blood  or  pus  which  may  be  found  adhering  to  its  sur- 
face or  tip.  With  the  hollow  bougie  provided  with  a  lateral  opening 
near  its  tip,  fragments  of  tissue  sufficiently  large  for  examination  may 
be  brought  away  by  the  instrument,  which  when  placed  under  the 
microscope  may  confirm  a  diagnosis  of  possible  malignancy. 


Esophagoscopy,  a  method  devised  by  Mikulicz,  consists  in  direct 
inspection  of  the  interior  of  the  esophagus  by  the  aid  of  a  long  endo- 
scopic tube  illuminated  by  electricity.  By  the  use  of  the  esophago- 
scope  in  the  hands  of  an  expert,  much  valuable  information  may  be 
obtained;  foreign  bodies  may  be  located  and  removed;  ulcers,  new 
growths,  strictures,  the  openings  of  diverticula,  etc.,  may  be  directly 
inspected;  and  fragments  of  tissue  may  be  removed  for  examination. 
Still,  the  discomfort  of  such  an  examination  for  the  patient  and  the 
experience  and  skill  required  in  the  use  of  the  instrument  on  the  part 
of  the  examiner  will  not  allow  it  to  supplant  the  ordinary  methods  of 
examination  as  a  routine. 

In  the  passage  of  the  esophagoscope  the  same  care  should  be 
observed  as  in  the  passage  of  any  esophageal  instruments.  The 
contraindications  to  its  use  are  practically  the  same  as  those  men- 
tioned for  the  sound  or  bougie,  viz.,  aortic  aneurysm,  recent  hem- 
orrhage from  the  esophagus,  advanced  pulmonary  or  cardiac  dis- 
ease, etc. 

Instruments. — Von  Mikulicz's  instruments  (Fig.  472)  are  cylin- 
drical tubes  about  2/5  to  1/2  inch  (10  to  13  mm.)  in  diameter,  bev- 
elled at  the  end  and  supplied  with  an  obturator  to  aid  in  their  intro- 
duction. On  the  outside,  the  tubes  are  marked  off  in  a  centimetric 
scale.  They  are  made  in  different  lengths,  according  to  the  depth  to 
which  it  is  wished  to  pass  the  instrument.  The  illumination  is  sup- 
plied by  a  panelectroscope  at  the  proximal  end  of  the  instrument. 
Among  other  instruments  of  this  type  may  be  mentioned  those  of 
Killian  and  Briinings. 

Other  tubes,  such  as  Jackson's  (Fig.  473)  or  Einhorn's,  for 
instance,  are  provided  with  illumination  at  the  distal  end  of  the 
instrument.  These  will  be  found  easier  to  manage,  as  with  the  former 
it  is  difficult  to  direct  the  Hght  properly  on  account  of  the  length  of 
the  tube.  To  examine  the  entire  length  of  the  esophagus,  Jackson 
uses,  for  adults,  a  tube  about  21  inches  (53  cm.)  long  and  2/5  inch  (10 



mm.)  thick,  and  for  children,  a  tube  i8  inches  (45  cm.)  long  and  7/25 
inch  (7  mm.)  thick.  In  addition  to  the  esophagoscope,  a  Sajous 
applicator,  swabs  on  holders,  various  shaped  forceps  for  removing 

Fig.  472. — Von  Mikulicz  set  of  instruments  for  esophagoscopy.      (Gottstein  in 

Keen's  Surgery.) 

foreign  bodies  or  sections  of  tissues  for  examination,  etc.,  are  required. 
Asepsis. — The  tubes  and  accessory  instruments  may  be  sterilized 
by  boiling  and  the  lights  by  immersion  in  alcohol. 

Fig.  473. — Jackson's  esophagoscope. 

Preparation  of  Patient. — The  patient's  stomach  should  be  empty, 
to  avoid  regurgitation  of  its  contents.  Where  there  is  a  marked 
dilatation  of  the  esophagus,  a  preliminary  lavage  (see  page  449)  may 



be  necessary.  The  clothing  should  be  loosened  from  about  the 
patient's  neck  and  chest  and  any  plates  or  artificial  teeth  should  be 
removed  from  the  mouth. 

Position  of  Patient. — Some  operators  perform  esophagoscopy 
with  the  patient  sitting  up;  others,  with  the  patient  on  a  table  in  a 
right  lateral  position,  with  the  head  supported  and  controlled  by  an 
assistant.  This  latter  posture,  or  that  known  as  Rose's  posture, 
viz.,  the  patient  recumbent  with  the  head  hanging  over  the  end  of  a 
table,  supported  by  an  assistant,  who  raises,  lowers,  or  turns  the  head 
at  will  (Fig.  474),  is  preferable. 

Fig.  474. — The  position  of  the  patient  and  assistant  for  esophagoscopy. 
(After  Jackson.) 

Anesthesia. — General  anesthesia  may  be  required  in  children. 
For  adults,  painting  the  pharynx,  larynx,  and  entrance  of  the  esopha- 
gus with  a  10  per  cent,  solution  of  cocain  by  means  of  a  cotton  swab 
held  in  a  Sajous  appHcator  some  minutes  before  the  introduction  of 
the  tube  will  suffice.  This  may  be  very  effectually  done  through  a 
short  split-tube  spatula,  such  as  is  used  in  direct  laryngoscopy  (see 
page  398). 

Technic. — The  seat  of  trouble  should  have  been  previously  deter- 
mined by  means  of  a  bougie,  and  if  the  operator  possesses  tubes  of 
different  lengths  this  will  enable  him  to  select  one  of  the  proper  length. 



The  tube  is  lubricated,  the  patient's  mouth  is  well  opened,  and,  with 
the  index-finger  of  the  left  hand,  the  base  of  the  tongue  is  drawn 

Fig.  475. — Shows  the  method  of  holding  the  esophagoscope.     (After  Jackson.) 

forward  (Fig.  476).     The  operator  then  introduces  the  tube,  with  the 
obturator  inserted  in  place,  backward  to  the  posterior  part  of  the 

Fig.  476. — First  step  in  esophagoscopy,  the  left  index-finger  guiding  the  in- 
strument into  the  esophagus.     (After  Jackson.) 

pharynx  and  then  downward,  the  assistant  at  the  same  time  extending 
the  patient's  head  so  as  to  bring  the  mouth  and  esophagus  nearly 

Fig.  477. — Shows  the  esophagoscope  in  place. 

in  the  same  straight  line.     The  patient  is  directed  to  aid  the  passage 
of  the  tube  by  swallowing.     As  soon  as  the  esophagus  has  been  well 


entered,  the  obturator  is  removed,  the  illumination  is  turned  on,  and 
the  tube  is  gently  pushed  on  into  the  canal  by  direct  sight,  the  sur- 
geon standing  or  being  seated  at  the  head  of  the  table  (Fig.  477). 
Under  direct  inspection  the  direction  of  the  esophagus  can  be  dis- 
tinguished and  the  tube  advanced  accordingly,  care  being  taken  to 
avoid  compression  of  the  trachea  by  a  faulty  direction  of  the  end  of 
the  tube.  In  the  cervical  portion,  the  walls  of  the  esophagus  lie  in 
apposition,  the  canal  being  represented  by  a  slit  extending  from  side 
to  side.  Below  the  level  of  the  sternum  the  canal  is  open.  The 
appearance  of  the  esophageal  mucous  membrane  differs  from  that  of 
the  trachea  in  that  it  has  not  the  deep  red  tint  of  the  latter,  but 
appears  pale  red  or  slightly  pink.  Any  mucus  or  regurgitated  matter 
from  the  stomach  that  blocks  the  end  of  the  tube  may  be  removed  by 
means  of  swabs  upon  long  applicators  or  by  the  aspirating  apparatus 
with  which  some  of  the  tubes  are  supplied.  In  this  manner  the  whole 
interior  of  the  canal  down  to  the  cardia  may  be  minutely  inspected, 
and  diseased  areas  treated  by  local  applications  if  desired.  Following 
the  operation,  if  there  is  pain  or  difficulty  in  swallowing,  cracked  ice 
in  small  quantities  mav  be  administered. 


The  X-rays  are  useful  in  locating  bones,  coins,  and  other  imper- 
vious foreign  bodies.  By  having  the  patient  first  swallow  bismuth  or 
similar  metallic  substances,  which  offer  resistance  to  the  penetration 
of  the  X-rays  and  are  capable  of  casting  a  shadow,  the  size,  shape, 
and  course  of  the  esophagus  may  be  outlined,  and  the  presence  of  a 
diverticulum,  constrictions,  or  dilatations  readily  recognized.  For 
this  purpose  a  mixture  of  bismuth  subcarbonate,  one  part,  to  two  of 
mucilage  of  acacia,  milk,  or  gruel  is  employed.  The  bismuth  forms 
a  coating  in  the  gullet  and  the  outline  of  the  tube  is  thus  represented 
upon  the  skiagraph  by  a  dark  shadow. 

Therapeutic  Measures 


Lavage  of  the  esophagus  is  employed  chiefly  for  the  purpose  of 
removing  collections  of  mucus  and  stagnated  or  decomposing  food 
particles  which  have  become  arrested  in  a  diverticulum  sac  or  in  a 
dilated  area  above  a  stenosis.     In  cancer  of  the  esophagus  it  is  fre- 




Fig.  478. — Apparatus  for  esophageal  lavage. 
a,  Fenestra  in  the  tip  of  the  tube;  b,  glass  funnel;  c,  mark  to   indicate  the  dis- 
tance from  the  teeth  to  the  stomach. 

Fig.  479. — Boas'  apparatus  for  esophageal  lavage.     (After  Gumprecht.) 


quently  employed  to  remove  foul  and  decomposed  products  of  the 
ulceration,  and  gives  much  relief  to  the  patient. 

Apparatus. — An  ordinary  stomach-tube,  about  a  No.  20  American 
in  size  and  30  inches  (75  cm.)  long,  provided  with  two  lateral  windows 
near  the  tip,  and  fitted  with  a  small  glass  funnel  at  its  proximal  end, 
forms  the  necessary  apparatus  (Fig.  478).  More  elaborate  apparatus 
has  been  devised  for  esophageal  lavage,  such  as,  for  example,  Boas* 
tube  (Fig.  479),  which  is  provided  with  an  inflatable  rubber  balloon 
for  closing  the  lower  end  of  the  esophagus,  thus  preventing  solution 
passing  the  cardia;  but  the  simple  apparatus  described  above  will 
answer  in  the  majority  of  cases. 

Asepsis. — The  tube  and  funnel  should  be  sterilized  by  boiling 
before  use. 

Solution. — For  simple  lavage  sterile  water  is  sufficient.  Solutions 
with  an  antiseptic  or  astringent  action  are  also  sometimes  employed. 

Temperature. — The  solution  should  be  introduced  warm,  i.e.,  at 
a  temperature  of  about  100°  F.  (38°  C). 

Frequency .^ — In  some  cases  the  lavage  will  be  required  as  fre- 
quently as  every  day;  in  other  cases  once  every  other  day  is  sufficient. 
It  should  preferably  be  performed  before  the  first  meal  of  the  day. 

Position  of  the  Patient.— The  patient  should  sit  in  a  chair,  or 
else  should  sit  up  in  bed  with  the  head  thrown  back  and  the  chin 
elevated.     The  operator  stands  in  front. 

Technic. — The  patient  is  protected  by  a  sheet  or  a  towel  fastened 
about  his  neck,  and  is  given  a  basin  to  hold  for  the  purpose  of  receiv- 
ing any  vomitus  that  may  be  expelled  during  the  passage  of  the 
tube.  He  then  opens  his  mouth  widely,  and  the  operator  slowly 
inserts  the  stomach-tube,  moistened  with  water  down  to  the  seat  of 
the  dilatation,  being  careful  at  first  to  keep  the  tip  of  the  instrument 
close  to  the  posterior  wall  of  the  pharynx  to  prevent  its  entering 
the  larynx.  The  funnel  end  is  then  raised  and  through  it  from  2  to 
2  1/2  ounces  (60  to  75  c.c.)  of  warm  water  are  poured  into  the 
esophagus.  The  funnel  end  is  then  lowered  and  the  contents  are 
drained  off.  By  alternately  pouring  in  solution  and  draining  it  off, 
the  esophagus  may  be  thoroughly  cleansed  and  all  particles  of  food 
or  mucus  removed. 



The  treatment  of  an  esophageal  stricture  comprises  dilatation 
by  means  of  bougies,  internal  esophagotomy,  external  esophagotomy, 



and,  when  the  stricture  is  impassable,  gastrostomy.  Gradual  dila- 
tation by  the  bougies  is  most  frequently  employed  and,  generally 
speaking,  is  the  best  form  of  treatment,  as  by  this  means  the  majority 
of  strictures  may  be  in  time  dilated.  The  tendency,  however,  is  for 
the  stricture  to  reform  after  dilatation  unless  a  bougie  be  passed  at 
intervals  during  the  remainder  of  the  patient's  life.  When  the 
stricture  involves  the  greater  part  of  the  canal,  dilatation  is  frequently 


Fig.  480. — The  most  frequent  seats  of  stricture  of  the  esophagus.  (Eisendrath.) 
A,  Aorta,  D,  Diaphragm,  i,  Stenosis  from  carcinoma  of  lower  end  of  the 
pharynx  and  beginning  of  the  esophagus;  2,  stenosis  from  pressure  of  tumors  of 
the  neck;  3,  stenosis  due  to  aneurysm  of  the  arch  of  the  aorta;  4,  stenosis  as  the 
result  of  caustic  or  lye  burns;  5,  stenosis  as  result  of  carcinoma  of  lower  end  of 
the  esophagus  and  cardiac  end  of  stomach. 

unsuccessful.  Dilatation  is  contraindicated  in  very  recent  burns  of 
the  esophagus.  Moderate  and  carefully  performed  dilatation,  how- 
ever, is  not  contraindicated  by  carcinoma. 

Strictures  may  be  located  in  any  part  of  the  esophagus,  but  the 
majority  are  situated  near  the  points  of  normal  constriction  of  the 


canal  (Fig.  480).  They  are  usually  single,  but  may  be  multiple, 
and  they  also  vary  in  form  and  shape,  being  valve-like,  annular, 
semicircular,  or  tortuous.  The  portion  of  the  canal  immediately 
above  a  tight  stricture  dilates  from  the  accumulation  of  food;  espe- 
cially is  this  the  case  if  the  stricture  is  low  in  the  canal,  and  as  a 
result  inflammation  or  suppuration  may  develop.     In  such  cases 

Fig.  481 — Cylindrical   esophageal  bougie. 

there  is  great  danger  of  perforating  the  walls  of  the  esophagus  unless 
extreme  gentleness  in  manipulation  is  observed. 

The  danger  of  passing  a  bougie  through  an  aneurysmal  sac  should 
also  be  kept  in  mind,  and  to  avoid  such  an  accident  a  careful  phys- 
ical examination  should  be  made  in  every  case  before  inserting  any 

Fig.  482. — Conical  esophageal  bougie. 

esophageal  instrument.  By  such  examination  the  discovery  of  other 
growths  within  the  neck  or  mediastinum  producing  compression  is 
often  possible.  It  is  next  necessary  to  determine  by  means  of  a 
bougie  the  location,  the  degree,  the  approximate  length,  and,  if 
possible,  the  character  of  the  stricture  before  any  attempts  at  dilata- 
tion are  made. 

Fig.  483. — Bulbous  esophageal  bougie. 

Instruments. — Flexible  bougies  of  woven  material  impregnated 
with  elastic  gum,  which  become  soft  when  placed  in  warm  water  and 
rigid  when  placed  in  cold  water,  are  generally  employed.  The 
bougies  vary  in  size  from  1/12  to  3/5  inch  (2  to  14  mm.).  In  a  nor- 
mal esophagus,  a  bougie  1/2  to  3/5  inch  (13  to  14  mm.)  in  diameter 
will  pass  the  narrow  portions  without  difficulty. 


For  strictures  of  fair  size,  say  the  size  of  a  lead  pencil,  cylindrical 
bougies  (Fig.  481)  may  be  employed;  for  smaller  strictures  the  con- 
ical (Fig.  482)  or  bulbous  instruments  (Fig.  483)  are  used. 

In  the  dilatation  of  very  tight  strictures  catgut  strings,  flexible 
whalebone,  or  linen  filiforms  similar  to  the  urethral  filiforms 
are  sometimes  employed.  They  are  inserted  by  the  aid  of  the 
esophagoscope  or  through  a  special  hollow  sound. 

Other  more  complicated  instruments  are  sometimes  used,  such 
as  Schreiber's  and  Billroth's  sounds.  The  former  (Fig.  484)  consists 
of  a  hollow  bougie  with  a  rubber  bag  on  the  dilating  end,  which  is 
capable  of  being  distended  with  fluid  forced  in  through  the  distal 
end  of  the  instrument.  Billroth's  sound  consists  of  a  cloth  sound 
filled  with  mercury.  These  instruments,  however,  possess  no  ad- 
vantages over  the  ordinary  flexible  bougie. 


Fig.  484. — Schreiber's  esophageal  sound.     (Gottstein  in  Keen's  Surgery.) 

Asepsis. — The  gum-elastic  bougies  may  be  sterilized  in  formalin 
vapor  or  by  immersion  in  a  saturated  boracic  acid  solution. 

Preparation  of  Patient. — In  cases  of  marked  dilatation  of  the 
canal  above  the  stenosis  full  of  stagnant  food  and  mucus,  prelimi- 
nary esophageal  lavage  (page  449)  is  indicated. 

Rapidity  of  Dilatation. — The  stretching  should  be  done  gradually. 
Rapid  dilatation  or  divulsion  is  dangerous  and  inadvisable. 

Frequency. — As  a  rule,  the  bougies  may  be  inserted  every  second 
or  third  day.  If  the  bougie  be  employed  too  frequently,  irritation 
at  the  seat  of  stricture  is  produced  and  the  condition  is  made  worse 
instead  of  improved.  After  full  dilatation  has  been  reached  the 
intervals  between  treatments  may  be  stretched  to  a  week,  and  then 
gradually  to  a  month.  The  patient  should  not  be  permitted  to  go 
longer  than  this,  however,  without  the  passage  of  a  bougie,  as  con- 
traction is  extremely  liable  to  develop.  At  any  signs  of  recurrence 
of  the  trouble,  more  frequent  treatments  are  necessary. 

Position  of  Patient. — The  patient  should  be  seated  in  a  chair  with 
the  head  thrown  well  back  and  with  the  chin  raised. 

Anesthesia. — Though  not  absolutely  necessary,  preliminary  co- 
cainization  of  the  pharynx  and  larynx  with  a  10  per  cent,  solution 
of  cocain  renders  the  operation  easier. 


Technic. — A  bougie  of  a  size  that  will  enter  the  stricture  is 
chosen.  This  is  determined  from  the  examination  of  the  stricture  pre- 
viously made.  The  bougie  is  softened  in  warm  water  and  bent  to  a 
gentle  curve  near  its  tip.  The  operator,  standing  in  front  of  the 
patient,  inserts  the  bougie  into  the  patient's  mouth  to  the  posterior 
wall  of  the  pharynx,  and,  keeping  it  close  to  this  latter  structure,  it 
is  slowly  advanced  into  the  esophagus  (see  Fig.  462).  If  difficulty 
is  encountered  in  entering  the  esophagus,  the  tongue  may  be  drawn 
forward  by  the  left  index-finger,  as  shown  in  Fig.  463. 

Fig.  485. — Von  Hacker's  method  of  introducing  thin  catgut  bougies.  (Gott- 
stein  in  Keen's  Surgery.)  a,  b,  c,  Into  the  stricture;  b' ,  through  a  wide  hollow 
bougie  {R). 

When  the  stricture  is  reached  care  must  be  taken  not  to  use  any 
force  in  attempting  to  pass  it,  as  a  false  passage  may  be  made  or  the 
instrument  may  simply  be  doubled  upon  itself.  By  gently  with- 
drawing and  then  advancing  the  instrument,  and  by  moving  its  tip 
in  different  directions,  the  opening  will  be  entered  if  the  particular 
instrument  is  of  sufficiently  small  caliber.  When  the  instrument  is 
once  within  the  stricture  the  operator  is  acquainted  with  the  fact 
by  the  tight  grasp  upon  the  bougie  exerted  by  the  stricture.  The 
bougie  should  be  slowly  passed  entirely  through  the  constriction,  and 
should  be  allowed  to  remain  in  place  from  five  to  ten  minutes  before 
it  is  withdrawn.     At  the  next  sitting  the  same  size  bougie  is  again 


inserted,  and,  if  the  stricture  seems  very  tight,  this  same  instniment 
may  be  passed  on  two  or  more  occasions  before  a  larger  one  is  em- 
ployed. When  there  is  more  than  one  stricture,  no  attempt  should 
be  made  to  dilate  the  lower  ones  until  dilatation  of  the  upper  is 

Very  tight  strictures  may  be  dilated  by  means  of  a  thread  passed 
through  the  stricture,  over  which  as  a  guide  are  passed  small 
olivary  bougies  or  conical  sounds  (see  page  444) ;  by  means  of  fili- 
form bougies  inserted  through  an  esophagoscope,  or  by  von  Hacker's 
method  of  inserting  catgut  strings.  In  the  latter  procedure  a  hollow 
sound  made  especially  for  inserting  catgut  strands  is  passed  down 
as  far  as  the  face  of  the  stricture,  and  through  this  the  catgut  strands 
are  insinuated  into  the  opening  one  after  another  in  a  manner  simi- 
lar to  the  method  used  for  tight  urethral  strictures  (Fig.  485).  They 
are  left  in  place  fifteen  to  thirty  minutes,  and,  as  the  gut  swells,  the 
contracture  is  stretched.  As  soon  as  sufficient  dilatation  for  the 
passage  of  a  small  bougie  has  been  thus  produced,  bougies  of  a  con- 
ical shape  may  be  substituted. 


This  consists  in  the  insertion  of  a  tube  into  a  stenosed  esophagus 
which  is  left  in  place  continuously  for  varying  periods  at  a  time.  It 
is  a  method  of  treatment  used  in  cancer  of  the  esophagus  when  the 
patient  is  unable  to  swallow  food,  and  sometimes  as  a  means  of  dilat- 
ing elastic  strictures  which  are  dilatable,  but  rapidly  contract  after 
the  withdrawal  of  a  bougie. 

Long  tubes  inserted  into  the  stomach  through  the  mouth  or  nose 
or  short  tubes  which  can  be  passed  through  the  stenosed  area  by  the 
aid  of  a  guide  are  employed.  The  use  of  the  short  tubes  is  preferable 
and  is  far  more  agreeable  for  the